Authors’ Reply: Which Surgical Operations Should be Performed in District Hospitals in East, Central and Southern Africa? Results of a Survey of Regional Clinicians

BACKGROUND In East, Central and Southern Africa (ECSA), district hospitals (DH) are the main source of surgical care for 80% of the population. DHs in Africa must provide basic life-saving procedures, but the extent to which they can offer other general and emergency surgery is debated. Our paper contributes to this debate through analysis and discussion of regional surgical care providers' perspectives. METHODS We conducted a survey at the College of Surgeons of East, Central and Southern Africa Conference in Kigali in December 2018. The survey presented the participants with 59 surgical and anaesthesia procedures and asked them if they thought the procedure should be done in a district level hospital in their region. We then measured the level of positive agreement (LPA) for each procedure and conducted sub-analysis by cadre and level of experience. RESULTS We had 100 respondents of which 94 were from ECSA. Eighteen procedures had an LPA of 80% or above, among which appendicectomy (98%), caesarean section (97%) and spinal anaesthesia (97%). Twenty-one procedures had an LPA between 31 and 79%. The surgical procedures that fell in this category were a mix of obstetrics, general surgery and orthopaedics. Twenty procedures had an LPA below 30% among which paediatric anaesthesia and surgery. CONCLUSION Our study offers the perspectives of almost 100 surgical care providers from ECSA on which surgical and anaesthesia procedures should be provided in district hospitals. This might help in planning surgical care training and delivery in these hospitals.


Dear Editor,
We thank Priyanch Nathani et al. for the evidence from India that endorses the importance of providing essential surgery at district hospitals (DHs), following our article [1]. We welcome the analysis linking our survey results with population-based needs for essential surgical operations from India and agree with the need for more evidencebased strategies to help DHs to meet the surgical needs of populations. Our study was the first empirical attempt to define an essential district-level surgical package for East, Central and Southern Africa, which could be replicated in India and other low-and middle-income countries (LMICs).
As highlighted by Nathani et al., more evidence is needed on the reasons behind the low level of positive agreement expressed by clinicians on delivery of a subset of certain operations at DHs, in particular 'high demand' procedures. Collaborative work to define the essential surgical package at district level in LMICs should focus on deepening our understanding on how to reach agreement on what package of surgeries is essential in what context. A critical factor in interpreting the Group 2 procedures, where surgeons' levels of positive agreement ranged from 31 to 79%, is that it includes what are often emergency lifesaving major interventions-hysterectomy, splenectomy and bowel resection-where timely (life-saving) referral of patients to a specialist centre is simply not feasible.
This leads to a second critical and sensitive issue: identifying who will perform these operations in DHs, in view of the inability of many countries to place and retain specialist surgeons and anaesthetists in district hospitals. Lessons learned from interventions such as COST-Africa [2] and SURG-Africa [3] have demonstrated how to increase access to safe and effective essential surgery at district level. The tested model uses specialist surgeons and anaesthetists to train, supervise and mentor surgical teams, including non-physician clinicians (NPCs) and general medical officers, to undertake many of these procedures. Task sharing major surgery to DH-based NPCs may raise concerns, which is why we need to further build the evidence base, by demonstrating the safety and effectiveness of these models [4].
Finally, it is essential to prioritise DHs in national funding allocations to different healthcare facilities. We join Nathani et al. in calling international funders who invest in strengthening health systems to prioritise investment in DHs. A way forward to crystallise political will on improving surgical care delivery in DHs is to ensure that empirically demonstrated feasible, safe and effective models of district surgical care are included in National Surgical Obstetrics and Anaesthesia Plan. The surgical needs of rural and district populations must be prioritised if global disease burden goals are to be achieved.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons. org/licenses/by/4.0/.