Elsevier

Surgery

Volume 155, Issue 3, March 2014, Pages 365-373
Surgery

Original Communication
Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: Operative capacities of 78 district hospitals in 7 low- and middle-income countries

https://doi.org/10.1016/j.surg.2013.10.008Get rights and content

Background

Surgery has been neglected in low- and middle-income countries for decades. It is vital that the Post-2015 Development Agenda reflect that surgery is an important part of a comprehensive global health care delivery model. We compare the operative capacities of multiple low- and middle-income countries and identify critical gaps in surgical infrastructure.

Methods

The Harvard Humanitarian Initiative survey tool was used to assess the operative capacities of 78 government district hospitals in Bangladesh (n = 7), Bolivia (n = 11), Ethiopia (n = 6), Liberia (n = 11), Nicaragua (n = 10), Rwanda (n = 21), and Uganda (n = 12) from 2011 to 2012. Key outcome measures included infrastructure, equipment availability, physician and nonphysician surgical providers, operative volume, and pharmaceutical capacity.

Results

Seventy of 78 district hospitals performed operations. There was fewer than one surgeon or anesthesiologist per 100,000 catchment population in all countries except Bolivia. There were no physician anesthesiologists in any surveyed hospitals in Rwanda, Liberia, Uganda, or in the majority of hospitals in Ethiopia. Mean annual operations per hospital ranged from 374 in Nicaragua to 3,215 in Bangladesh. Emergency operations and obstetric operations constituted 57.5% and 40% of all operations performed, respectively. Availability of pulse oximetry, essential medicines, and key infrastructure (water, electricity, oxygen) varied widely between and within countries.

Conclusion

The need for operative procedures is not being met by the limited operative capacity in numerous low- and middle-income countries. It is of paramount importance that this gap be addressed by prioritizing essential surgery and safe anesthesia in the Post-2015 Development Agenda.

Section snippets

Survey design

Surveys were conducted using a comprehensive survey tool adapted by the HHI from the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care.40 Both survey tools assessed operative capacity on the basis of the following eight areas of surgical provision: access and availability, human resources, infrastructure, outcomes recording, types of operations performed, equipment availability, blood products, and pharmaceutical capacity.

Data collection

Surveys were conducted from 2011 to 2012.

Surveyed hospitals

Seventy-eight government district hospitals were surveyed in seven LMICs: Bangladesh (n = 7),34 Bolivia (n = 11),35 Ethiopia (n = 6),32 Liberia (n = 11),33 Nicaragua (n = 10),38 Rwanda (n = 21),37 and Uganda (n = 12)36 (Table I).32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43 On the basis of gross national income per capita, the World Bank classifies five of these as low-income countries (Bangladesh, Ethiopia, Liberia, Rwanda, and Uganda) and two as lower-middle-income countries (Bolivia and

Discussion

The prevalence of surgical disease is on the rise.45 This is the result of an increase in noncommunicable diseases such as cancer and trauma as well as the fact that surgical services have been neglected in LMICs for decades.46 It is therefore important to understand the capacity of district hospitals to provide essential surgery and safe anesthesia. The objective of this study was to survey the operative capacities of district hospitals in multiple LMICs. We assessed a total of 78 government

Conclusion

The comparative data presented here represent a comprehensive summary of extensive data on surgical and anesthesia infrastructure in several LMICs. These data should inform the global public health community as the Post-2015 Development Agenda is being defined. No longer can the burden of surgical disease be denied as an important contributor to premature disability and death due to an absence of data. Essential surgery and safe anesthesia must be part of a comprehensive health strategy in

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    Funded by the Harvard Humanitarian Initiative, Harvard Program in Global Surgery and Social Change, Massachusetts General Hospital (MGH) Global Health Center of Expertise, MGH International Trauma and Disaster Institute, Brigham and Women's Hospital Department of Emergency Medicine, Thomas J. Watson Foundation, Global Surgical Consortium, Duke Global Health Residency/Fellowship Pathway, US Fulbright Program, and the Harvard School of Public Health.

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