The survey was completed by 100 respondents from 21 countries, of whom 94 were from Africa (see map in Fig. 1); with the majority coming from Rwanda, Uganda and Tanzania. Six respondents were based outside Africa and came from the USA, Ireland, Scandinavia and New Zealand, 79 respondents were surgeons (see Table 2).
Validation of Responses
The Cronbach's alpha for our survey is 0.91, which shows a high level of consistency. For the first 4 of the 7 pairs of complex/less complex procedures (shown in Table 1), all the respondents’ answers were consistent, i.e. none suggested that a complex procedure should be done in DHs while a less complex one should not. For the next 2 pairs, there was one inconsistent respondent, and, for the last pair, cleft lip repair/skin grafting, 4 respondents suggested that skin grafting should not be done, while cleft lip repair should.
The level of agreement for each procedure is shown in Fig. 2 (and Supplemental Table 1). On the left of Fig. 2 are the procedures where there is high agreement that they should be done at DHs; on the right are the procedures with least agreement. We arbitrarily identified three broad groups of procedures. Group 1: those procedures that a large majority think should definitely be done at DHs. Group 2: those where there was debate as to whether they should be done, and Group 3: those that a large majority thought should not be done. The three groups are identified by a different colour in Fig. 2, Group 1 is on the left, Group 2 in the middle and Group 3 on the right. There are dotted lines between the groups. Please note that these groups and the thresholds are arbitrary and for discussion only.
LPA of 80% or above, consisting of 18 procedures with broad consensus of 80% or more of participants that they should be done at DHs. The surgical procedure with the highest LPA was suprapubic catheterisation (99%), followed by appendicectomy (98%) and caesarean section (97%). The anaesthesia procedure with the highest LPA was spinal anaesthesia (97%). Ketamine anaesthesia reached 96% positive agreement and general anaesthesia for adults 91% (Fig. 2).
LPA of 31–79%, consisting of 21 procedures. There were two anaesthesia procedures in this category: regional nerve blocks (LPA = 53%) and anaesthesia administered to children under 5 years old (LPA = 38%). The surgical procedures that fell in this category were a mix of obstetrics, general surgery and orthopaedics. It is of note that all types of laparotomy fell into this category. Large bowel obstruction (51%), stoma formation (50%) and hysterectomy (48%) were in the middle of the group with almost half of respondents recommending that they were done, and the other half disagreeing.
LPA of below 30%, consisting of 20 procedures. Administering anaesthesia to children under 12 months and tonsillectomy had an LPA of 26%. The three procedures with the lowest LPA were thoracotomy (5%), gastroschisis surgery (3%) and oesophageal atresia repair (2%).
The Wilcoxon test showed no significant difference in terms of LPA (p-value = 0.3) between those we classified as “experienced” in DH surgery (84 respondents) and those “non-experienced” (14 respondents). No significant differences were found for all the other demographics characteristics (country of work, profession, qualification) of study participants in relation to their responses.
All 6 anaesthetists agreed that general, spinal, ketamine and local anaesthesia should be done at a DH. All but one anaesthetist agreed that regional blocks should not be administered at a DH, while 53% of non-anaesthetist respondents think they should be offered. Similarly, all but one anaesthetist agreed that paediatric anaesthesia should not be administered at DHs.