The Operative Output of District Hospitals in KwaZulu-Natal Province is Heavily Skewed Toward Obstetrical Care

Are LMICs Achieving the Lancet Commission Global Benchmark for Surgical Volumes? A Systematic Review

INTRODUCTION

The Lancet Commission on Global Surgery (LCoGS) set the benchmark of 5000 procedures per 100,000 population annually to meet surgical needs adequately. This systematic review provides an overview of the last ten years of surgical volumes in Low and Middle- Income-Countries (LMICs).

METHODOLOGY

We searched PubMed, Web of Science, Scopus, Cochrane, and EMBASE databases for studies from LMICs addressing surgical volume. The number of surgeries performed per 100,000 population was estimated. We used cesarean sections, hernia, and laparotomies as index cases for the surgical capacities of the country. Their proportions to total surgical volumes were estimated. The association of country-specific surgical volumes and the proportion of index cases with its Gross Domestic Product (GDP) per capita was analyzed.

RESULTS

A total of 26 articles were included in this review. In LMICs, on average, 877 surgeries were performed per 100,000 population. The proportion of cesarean sections was found to be high in all LMICs, with an average of 30.1% of the total surgeries, followed by hernia (16.4%) and laparotomy (5.1%). The overall surgical volumes increased as the GDP per capita increased. The proportions of cesarean section and hernia to total surgical volumes decreased with increased GDP per capita. Significant heterogeneity was found in the methodologies to assess surgical volumes, and inconsistent reporting hindered comparison between countries.

CONCLUSION

Most LMICs have surgical volumes below the LCoGS benchmark of 5000 procedures per 100,000 population, with an average of 877 surgeries. The surgical volume increased while the proportions of hernia and cesarean sections reduced with increased GDP per capita. In the future, it's essential to apply uniform and reproducible data collection methods for obtaining multinational data that can be more accurately compared.

The Burden of Emergency Abdominal Surgery Heavily Outweighs Elective Procedures in KwaZulu-Natal Province, South Africa

BACKGROUND

South Africa is a middle-income country with major discrepancies in wealth and access to care. There is a significant burden of surgical disease and limited access to quality health care for a large proportion of the population. This article quantifies the burden of abdominal surgery over a 6-month period in KwaZulu-Natal (KZN) province and quantifies the emergency to elective (Ee) ratio for these operations.

METHODS

This study describes the abdominal operations conducted at all regional and tertiary hospitals in the public health sector of KZN province for the period of 1 July to December 31, 2015. Operations performed were tabulated in a spreadsheet and categorized as elective, emergency, and trauma. They were further subdivided by anatomical region and by specific predetermined procedures. Uncertain criteria were clarified using a modified Delphi discussion. The Ee ratio was determined using the recently described technique.

RESULTS

Between June, 1st and December 31, 2015, of 13,282 operations, there were 4580 (34.5%) elective operations, 7777 (58.6%) emergency operations, and 925 (6.9%) trauma-related operations. A total of 5630 abdominal operations were performed of which 2949 were emergency procedures. There were 660 trauma-related abdominal procedures and 2021 elective procedures. There was a heavy weighting toward emergency surgeries with an Ee ratio of 145 for abdominal surgery. The previous sub-Saharan African ratio was estimated to be 62.6.

CONCLUSIONS

An overview of abdominal surgery in KZN reveals a high ratio of emergency to elective surgery. This suggests that the current primary health care program is failing to detect and treat acute surgical disease timeously.