A Call to Action: Translating Procedural Baskets into Improved Surgical Capacity at the District Hospital
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INVITED COMMENTARY
A Call to Action: Translating Procedural Baskets into Improved Surgical Capacity at the District Hospital Kathryn M. Chu1
•
Riaan Duvenage2,3
Accepted: 10 October 2020 Ó Socie´te´ Internationale de Chirurgie 2020
Introduction Strengthening surgical services in low- and middle-income countries (LMICs) is a key component to improving equitable surgical access and decreasing mortality from surgical conditions. Since 2015, there has been increasing recognition that the provision of essential and emergency surgical care (EESC) should be a global health priority and the majority of EESC procedures should be provided at the district (first-level) hospital. Many LMICs have tiered public health systems which concentrate surgical care at second- and third-level hospitals where fully qualified surgeons, anesthesiologists, and obstetricians work. On the other hand, most district hospitals have limited surgical capacity and are staffed by general doctors, family physicians, or mid-level (non-physician clinician) providers, whose surgical, anesthetic, and obstetric training can be variable and not subjected to regulatory oversight. & Kathryn M. Chu [email protected] Riaan Duvenage [email protected] 1
Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie Van Zijl Drive, Tygerberg 7505, South Africa
2
Department of Surgery, Worcester Regional Hospital, Worcester 6850, South Africa
3
Ukwanda Centre for Rural Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
The case for strengthening district hospital surgical capacity is compelling. Health care provided closer to the community has been shown to have improved outcomes for other types of medical conditions and to reduce patient outof-pocket expenditures and improve health-seeking behavior. In some LMICs, there are long delays to surgical care at higher-level hospitals which can result in increased mortality. A higher level of EESC provided by district hospitals would greatly improve equitable access for patients and decrease the burden on higher-level hospitals [1]. Defining an appropriate basket of procedures for district hospitals is critical to strengthening surgical capacity. In 2015, the authors of Essential Surgery: Disease Control Priorities, defined 44 EESC procedures, 28 of which were considered appropriate for the LMIC district hospital [2]. In this issue, Bentounsi et al. [3] have created an East, Central, and Southern Africa-specific district hospital list by surveying 100 operating theatre personnel working in the region including surgeons from various specialties, anesthesiologists, obstetricians, medical students, and midlevel providers. Participants ranked 59 pre-selected procedures which were then stratified into three levels of concordance. More than 80% of participants agreed on eighteen procedures as appropriate for district hospitals. Amongst these, suprapubic catheterization, C
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