{
  "generatedAt": "2026-04-16T22:22:58Z",
  "methodology": {
    "title": "Methodology",
    "sections": [
      {
        "title": null,
        "blocks": [
          {
            "type": "h1",
            "text": "Methodology"
          },
          {
            "type": "p",
            "text": "This page describes the analytical framework, categorization criteria, and methodological decisions underlying the Global Orthopaedic Atlas. Our approach balances statistical rigor with practical interpretability for healthcare policy and workforce planning."
          }
        ]
      },
      {
        "title": "Conceptual Framework",
        "blocks": [
          {
            "type": "p",
            "text": "The atlas operationalizes orthopaedic surgical capacity as the availability of trained specialists relative to population need. This is measured through two primary metrics:"
          },
          {
            "type": "ol",
            "items": [
              "Surgeon Density: Orthopaedic surgeons per 100,000 population (primary metric)",
              "Training Infrastructure: Number of accredited training programs per country (secondary metric)"
            ]
          },
          {
            "type": "p",
            "text": "These metrics align with the Lancet Commission on Global Surgery's framework for measuring surgical system capacity and are consistent with WHO workforce density benchmarking methodologies."
          }
        ]
      },
      {
        "title": "Surgeon Density Calculation",
        "blocks": [
          {
            "type": "h3",
            "text": "Numerator Definition: \"Practicing Orthopaedic Surgeons\""
          },
          {
            "type": "p",
            "text": "Included:"
          },
          {
            "type": "ul",
            "items": [
              "Physicians with recognized orthopaedic surgery specialty training/certification",
              "Actively engaged in clinical practice (≥50% clinical time)",
              "All subspecialties (trauma, sports, hand, spine, paediatric, oncology, etc.)",
              "Public and private sector practitioners"
            ]
          },
          {
            "type": "p",
            "text": "Excluded:"
          },
          {
            "type": "ul",
            "items": [
              "Retired surgeons (not in active clinical practice)",
              "Full-time academic/research positions without clinical duties",
              "Physicians-in-training (residents, fellows) - counted separately in training metrics",
              "Related specialties without formal orthopaedic training (e.g., podiatrists, physiatrists)"
            ]
          },
          {
            "type": "h3",
            "text": "Denominator: Population Estimates"
          },
          {
            "type": "ul",
            "items": [
              "World Bank 2024 population estimates used for all countries",
              "Mid-year estimates to align with surgeon count reference dates",
              "No adjustment for age structure (i.e., total population, not surgical-age population)"
            ]
          },
          {
            "type": "p",
            "text": "Methodological Note: Use of total population (rather than surgical-age population) follows WHO convention and facilitates international comparability. However, this may underestimate capacity in countries with young populations and overestimate in ageing societies."
          }
        ]
      },
      {
        "title": "Capacity Categorization System",
        "blocks": [
          {
            "type": "p",
            "text": "Countries are classified into four capacity categories based on surgeon density thresholds. These categories are empirically derived from the global distribution and informed by health workforce planning literature."
          },
          {
            "type": "table",
            "rows": [
              [
                "Category",
                "Density Threshold",
                "Color Code",
                "Characteristics"
              ],
              [
                "High Capacity",
                "≥2.0 per 100,000",
                "Dark Green",
                "Meet or exceed WHO-recommended specialist density; robust training infrastructure"
              ],
              [
                "Upper-Middle",
                "0.5 - 1.99 per 100,000",
                "Light Green",
                "Moderate capacity; regional hubs often present; may have urban-rural disparities"
              ],
              [
                "Lower-Middle",
                "0.1 - 0.49 per 100,000",
                "Orange",
                "Substantial shortages; limited subspecialty coverage; concentrated in capital cities"
              ],
              [
                "Critical Shortage",
                "<0.1 per 100,000",
                "Red",
                "Severe workforce crisis; minimal or no training capacity; reliance on international aid"
              ]
            ]
          },
          {
            "type": "h3",
            "text": "Threshold Derivation"
          },
          {
            "type": "p",
            "text": "The 2.0 per 100,000 threshold for \"High Capacity\" is based on:"
          },
          {
            "type": "ul",
            "items": [
              "Observed densities in high-income countries with universal health coverage (median: 2.4/100k)",
              "Lancet Commission recommendation of 20-40 surgical specialists per 100,000 for all surgical disciplines combined",
              "Assuming orthopaedics represents ~10-15% of surgical workforce, implies 2-6/100k as adequate range"
            ]
          },
          {
            "type": "p",
            "text": "The \"Critical Shortage\" threshold (<0.1/100k) represents the bottom decile of global distribution and aligns with UN Least Developed Countries (LDC) health workforce benchmarks."
          }
        ]
      },
      {
        "title": "Data Collection Process",
        "blocks": [
          {
            "type": "h3",
            "text": "1 Initial Data Extraction"
          },
          {
            "type": "p",
            "text": "Primary data extracted from WHO Global Health Observatory (GHO), national medical councils, and professional society databases. Automated scraping where APIs available; manual extraction from annual reports for others."
          },
          {
            "type": "h3",
            "text": "2 Cross-Source Validation"
          },
          {
            "type": "p",
            "text": "Each data point verified against minimum two independent sources. Discrepancies >10% flagged for manual review. Conservative estimate (lower bound) used when sources conflict."
          },
          {
            "type": "h3",
            "text": "3 Expert Ground-Truthing"
          },
          {
            "type": "p",
            "text": "OrthoGlobe Collaborative members surveyed to validate official statistics. Particularly critical for countries with weak registry systems or outdated WHO data. Expert consensus used to adjust figures where appropriate (documented in audit trail)."
          },
          {
            "type": "h3",
            "text": "4 Temporal Standardization"
          },
          {
            "type": "p",
            "text": "All surgeon counts standardized to reference year 2024-2025. Where only historical data available, linear projection applied based on medical school graduation rates (capped at ±15% adjustment)."
          },
          {
            "type": "h3",
            "text": "5 Quality Scoring"
          },
          {
            "type": "p",
            "text": "Each country's data assigned a quality score (A-D) based on source reliability, recency, and verification level. Low-quality estimates (D-grade) flagged in dataset with confidence intervals."
          }
        ]
      },
      {
        "title": "Training Program Inclusion Criteria",
        "blocks": [
          {
            "type": "p",
            "text": "To be included in the training program count, a program must meet all of the following:"
          },
          {
            "type": "table",
            "rows": [
              [
                "Criterion",
                "Requirement"
              ],
              [
                "Accreditation",
                "Recognized by national medical authority, WHO-listed institution, or WFME-accredited"
              ],
              [
                "Duration",
                "Minimum 3-year structured curriculum (residency) or 1-year (fellowship)"
              ],
              [
                "Active Status",
                "Currently enrolling trainees; graduated ≥1 trainee in past 3 years"
              ],
              [
                "Specialty Focus",
                "Primary focus on orthopaedic surgery (not general surgery with ortho rotation)"
              ],
              [
                "Clinical Volume",
                "Minimum 500 orthopaedic procedures annually (where data available)"
              ]
            ]
          }
        ]
      },
      {
        "title": "Analytical Limitations & Uncertainties",
        "blocks": [
          {
            "type": "h3",
            "text": "Geographic Aggregation"
          },
          {
            "type": "p",
            "text": "National-level data masks intra-country disparities. Urban centers typically have 5-10× higher surgeon density than rural areas. For federal systems (USA, India, Brazil), state-level data would be more informative but is inconsistently available."
          },
          {
            "type": "h3",
            "text": "Public vs. Private Sector"
          },
          {
            "type": "p",
            "text": "In countries with large private sectors (e.g., India, UAE, South Africa), total surgeon counts may underestimate capacity accessible to low-income populations who rely on public facilities."
          },
          {
            "type": "h3",
            "text": "Workload & Productivity"
          },
          {
            "type": "p",
            "text": "Surgeon density does not account for surgical volume per surgeon. A surgeon in a low-resource setting may perform 2-3× more procedures than counterparts in high-income countries, partially compensating for lower density."
          },
          {
            "type": "h3",
            "text": "Subspecialty Mix"
          },
          {
            "type": "p",
            "text": "Current dataset does not disaggregate by subspecialty. A country might have adequate total orthopaedic capacity but critical shortages in specific areas (e.g., paediatric orthopaedics, hand surgery)."
          },
          {
            "type": "h3",
            "text": "Temporal Lag"
          },
          {
            "type": "p",
            "text": "Most recent official data lags 12-24 months. In rapidly changing contexts (e.g., conflict zones, post-pandemic workforce shifts), current capacity may differ substantially from reported figures."
          }
        ]
      },
      {
        "title": "Statistical Approach",
        "blocks": [
          {
            "type": "h3",
            "text": "Missing Data Handling"
          },
          {
            "type": "ul",
            "items": [
              "Complete absence: Country excluded from atlas (not estimated)",
              "Partial data: Multiple imputation from regional benchmarks (flagged as \"estimated\")",
              "Outdated data (>5 years): Expert adjustment or exclusion"
            ]
          },
          {
            "type": "h3",
            "text": "Uncertainty Quantification"
          },
          {
            "type": "p",
            "text": "For countries with robust data (A/B quality grade): ±5% precision For estimated values (C/D grade): 95% confidence intervals reported where possible"
          }
        ]
      },
      {
        "title": "Validation & Peer Review",
        "blocks": [
          {
            "type": "p",
            "text": "The atlas methodology has been reviewed by:"
          },
          {
            "type": "ul",
            "items": [
              "OrthoGlobe Collaborative Scientific Advisory Board (12 members, 6 continents)",
              "External peer reviewers from SICOT, ISAKOS, and WHO Global Surgery Unit",
              "Feedback incorporated from pilot launch (October 2025) with 50 surgeon-users across 25 countries"
            ]
          }
        ]
      },
      {
        "title": "Updates & Version Control",
        "blocks": [
          {
            "type": "p",
            "text": "This methodology document corresponds to Atlas Version 1.0 (March 2026). Methodological changes will be documented in future versions with clear rationale for modifications."
          },
          {
            "type": "p",
            "text": "For methodological queries or to report data quality concerns, contact: mo.imam@nhs.net"
          }
        ]
      }
    ]
  },
  "dataSources": {
    "title": "Data Sources & References",
    "sections": [
      {
        "title": null,
        "blocks": [
          {
            "type": "h1",
            "text": "Data Sources & References"
          },
          {
            "type": "p",
            "text": "The Global Orthopaedic Atlas compiles data from multiple authoritative sources to provide an accurate snapshot of global orthopaedic surgical capacity. This page documents our data sources, collection methodology, and quality assurance processes."
          }
        ]
      },
      {
        "title": "Primary Data Sources",
        "blocks": [
          {
            "type": "h3",
            "text": "WHO Global Health Workforce Statistics"
          },
          {
            "type": "p",
            "text": "Coverage: 194 countries and territories"
          },
          {
            "type": "p",
            "text": "Data Type: Surgeon workforce density, health infrastructure metrics"
          },
          {
            "type": "p",
            "text": "Update Frequency: Annual (most recent: 2024)"
          },
          {
            "type": "p",
            "text": "Reliability: High - based on national health ministry reporting"
          },
          {
            "type": "h3",
            "text": "National Medical Councils & Registries"
          },
          {
            "type": "p",
            "text": "Countries Covered: 35+ jurisdictions with publicly accessible registries"
          },
          {
            "type": "p",
            "text": "Data Type: Specialist registration data, subspecialty distributions"
          },
          {
            "type": "p",
            "text": "Examples:"
          },
          {
            "type": "ul",
            "items": [
              "UK: General Medical Council (GMC) Specialist Register",
              "USA: American Academy of Orthopaedic Surgeons (AAOS) membership data",
              "Australia: Australian Orthopaedic Association (AOA) registry",
              "India: National Medical Commission specialist database",
              "South Africa: Health Professions Council of South Africa (HPCSA)"
            ]
          },
          {
            "type": "p",
            "text": "Reliability: Very High - official regulatory data"
          },
          {
            "type": "h3",
            "text": "Published Academic Literature"
          },
          {
            "type": "p",
            "text": "Search Strategy: PubMed, Embase, WHO Global Index Medicus (2020-2026)"
          },
          {
            "type": "p",
            "text": "Keywords: \"orthopaedic surgeon density\", \"surgical workforce capacity\", \"global orthopaedic training\""
          },
          {
            "type": "p",
            "text": "Studies Included: 47 peer-reviewed publications"
          },
          {
            "type": "p",
            "text": "Key References:"
          },
          {
            "type": "ul",
            "items": [
              "Meara JG, et al. \"Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.\" Lancet. 2015;386(9993):569-624.",
              "Alkire BC, et al. \"Global access to surgical care: a modelling study.\" Lancet Glob Health. 2015;3(6):e316-23.",
              "Holmer H, et al. \"Global distribution of surgeons, anaesthesiologists, and obstetricians.\" Lancet Glob Health. 2015;3 Suppl 2:S9-11."
            ]
          },
          {
            "type": "h3",
            "text": "Professional Society Data"
          },
          {
            "type": "p",
            "text": "Organizations Surveyed:"
          },
          {
            "type": "ul",
            "items": [
              "International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT)",
              "Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)",
              "International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS)",
              "AO Foundation global membership database",
              "College of Surgeons of East, Central and Southern Africa (COSECSA)"
            ]
          },
          {
            "type": "p",
            "text": "Data Type: Training center directories, fellowship program listings, membership demographics"
          },
          {
            "type": "h3",
            "text": "OrthoGlobe Collaborative Network"
          },
          {
            "type": "p",
            "text": "Contributors: 200+ orthopaedic surgeons across 65 countries"
          },
          {
            "type": "p",
            "text": "Data Type: Ground-truth verification, local training program details, resource availability assessments"
          },
          {
            "type": "p",
            "text": "Method: Structured surveys and expert consultation (2024-2026)"
          },
          {
            "type": "p",
            "text": "Purpose: Validation of official statistics and gap-filling for underreported regions"
          }
        ]
      },
      {
        "title": "Data Collection & Processing",
        "blocks": [
          {
            "type": "h3",
            "text": "Surgeon Density Calculation"
          },
          {
            "type": "p",
            "text": "Surgeon density is calculated as:"
          },
          {
            "type": "p",
            "text": "Density = (Number of Practicing Orthopaedic Surgeons ÷ Total Population) × 100,000"
          },
          {
            "type": "ul",
            "items": [
              "Numerator: Actively practicing orthopaedic surgeons (excludes retirees, non-clinical roles)",
              "Denominator: Total national population (World Bank 2024 estimates)",
              "Subspecialty Inclusion: All orthopaedic subspecialties included (trauma, sports, hand, spine, paediatric, etc.)"
            ]
          },
          {
            "type": "h3",
            "text": "Training Program Verification"
          },
          {
            "type": "p",
            "text": "Training programs included in the atlas meet the following criteria:"
          },
          {
            "type": "ol",
            "items": [
              "Accredited by national medical authority or recognized international body",
              "Minimum 3-year structured training curriculum",
              "Active as of January 2026",
              "Accepts new trainees annually"
            ]
          }
        ]
      },
      {
        "title": "Data Quality Assurance",
        "blocks": [
          {
            "type": "table",
            "rows": [
              [
                "Quality Criterion",
                "Method",
                "Threshold"
              ],
              [
                "Source Verification",
                "Cross-reference ≥2 independent sources",
                "95% agreement required"
              ],
              [
                "Temporal Consistency",
                "Compare year-over-year trends",
                "Flag >20% annual change for review"
              ],
              [
                "Expert Validation",
                "OrthoGlobe network ground-truth check",
                "Local surgeon confirmation for each country"
              ],
              [
                "Outlier Detection",
                "Statistical analysis (Z-score >3)",
                "Manual investigation of outliers"
              ]
            ]
          }
        ]
      },
      {
        "title": "Data Limitations",
        "blocks": [
          {
            "type": "p",
            "text": "Important Note: Users should be aware of the following limitations when interpreting atlas data:"
          },
          {
            "type": "ul",
            "items": [
              "Reporting Gaps: Some countries lack centralized surgeon registries; estimates may rely on professional society membership (typically underestimates true numbers)",
              "Definition Variability: \"Orthopaedic surgeon\" definitions vary across countries (some include trauma surgeons, others separate them)",
              "Private Sector: Private practice surgeons may be underreported in countries with weak regulatory oversight",
              "Temporal Lag: Most recent official data lags 1-2 years; rapid changes (e.g., conflict zones, mass migration) may not be captured",
              "Training Quality: Program counts reflect quantity, not quality; accreditation standards vary globally",
              "Subspecialty Distribution: Current dataset does not disaggregate by subspecialty (e.g., shoulder vs. spine specialists)"
            ]
          }
        ]
      },
      {
        "title": "Update Schedule",
        "blocks": [
          {
            "type": "p",
            "text": "The Global Orthopaedic Atlas is updated on a rolling basis:"
          },
          {
            "type": "ul",
            "items": [
              "Quarterly reviews: New WHO data, major national registry updates",
              "Annual refresh: Comprehensive re-validation of all countries (Target: January each year)",
              "Ad-hoc updates: Significant events (new training programs, policy changes) incorporated as identified"
            ]
          }
        ]
      },
      {
        "title": "Data Access & Reuse",
        "blocks": [
          {
            "type": "p",
            "text": "The Global Orthopaedic Atlas data is made available for academic, educational, and advocacy purposes. Researchers wishing to access the underlying dataset for analysis should contact mo.imam@nhs.net with details of their proposed use."
          },
          {
            "type": "p",
            "text": "Citation:"
          },
          {
            "type": "p",
            "text": "Imam MA. Global Orthopaedic Atlas: An Interactive Map of Surgical Capacity and Training Worldwide. OrthoGlobe Collaborative. 2026. Available at: https://orthoglobe.org/atlas"
          }
        ]
      }
    ]
  }
}