Research Article: Essential Surgery at the District Hospital: A Retrospective Descriptive Analysis in Three African Countries

Date Published: March 9, 2010

Publisher: Public Library of Science

Author(s): Moses Galukande, Johan von Schreeb, Andreas Wladis, Naboth Mbembati, Helder de Miranda, Margaret E. Kruk, Sam Luboga, Alphonsus Matovu, Colin McCord, S. Khady Ndao-Brumblay, Doruk Ozgediz, Peter C. Rockers, Ana Romàn Quiñones, Fernando Vaz, Haile T. Debas, Sarah B. Macfarlane, Theo Vos

Abstract: In the first of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues find low levels of surgical care provision suggesting unmet need for surgical services.

Partial Text: The current drive towards a health systems approach for delivering health care interventions in Africa opens an opportunity to redress long-standing neglect in the provision of surgical services [1],[2]. Health systems must be flexible enough not only to prevent and treat the high morbidity and mortality from infectious diseases and the increasing prevalence of noncommunicable conditions, but also to alleviate conditions requiring prompt surgical interventions such as obstetric emergencies and trauma cases [3]. The traditional referral-based system in which patients are provided primary health care at first-level referral facilities and referred to secondary and tertiary health care facilities for specialized care has undermined the capacity to provide timely access to essential surgical procedures. Although some surgical conditions can be postponed until the patient can gain access to specialized care, others result in death or severe disability if treatment is delayed. This situation is clearly highlighted in the case of obstetric emergencies in which it is recognized that in order to prevent maternal deaths, cesarean sections can be provided at some first referral facilities, and must be provided at district hospitals. We argue that the same basic surgical skills and equipment needed to perform emergency obstetric procedures are required to treat other surgical conditions and therefore that building surgical capacity has the potential to improve a range of health outcomes.

Catchment populations ranged from about 99,000 to 628,000 people (Table 2). Admissions ranged from 3,861 to 16,999 and deliveries from 439 to 3,607. Facilities were staffed with one to six doctors and three to 26 mid-level health providers. The number of hospital beds per 1,000 population ranged from 0.2 to 1.

We found relatively low rates of major surgery at district hospitals in East Africa, ranging from 50 to 450 surgical procedures per 100,000 population. Although lack of data on the population need for surgery precludes conclusions about the magnitude of unmet need, this confirms that there are barriers to access to essential surgery in at least some rural districts in Uganda, Tanzania, and Mozambique. This is reinforced by our finding that the majority of nonobstetric surgery was for emergency rather than elective conditions, suggesting that district residents do not receive surgical care for common surgical conditions (e.g., inguinal hernia repair) in local hospitals.



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