Access to surgical care in Ethiopia: a cross-sectional retrospective data review

Health facility based cross-sectional study with retrospective data review was conducted in public and private health facilities of Ethiopia from December 30, 2020 to June 10, 2021. Ethiopia is an east African country with estimated population of more than 117 million people in 2021 [10]. A total of 282 government health facilities and 45 private hospitals were providing surgical care in the country during the study period.

A multi-stage stratified random sampling method was used to select study sites (public and private health care facilities). First, lists of all health care facilities providing surgical care were obtained from MOH of Ethiopia’s District Health Information System 2 (DHIS 2) report. Accordingly, 282 government hospitals (26 specialized hospitals, 75 general hospitals, and 181 primary hospitals) were providing EESC during the study period. The required sample size for the study was estimated using a single population proportion formula with a 95% level of confidence, a 5% margin of error, and an assumed proportion of surgical care accessibility (P = 0.5); therefore, the sample size was estimated to be 163 public hospitals. As we used a stratified sampling method, the sample size for each stratum of primary hospitals (n_p), general hospitals (n_g), and specialized hospitals (n_s) was calculated using the proportional allocation method and it was 105, 43, and 15 hospitals, respectively. In addition, to assess the status of surgical care in the private health sector, private health facilities providing safe surgical care services were included. According to DHSI 2 report, 45 private health facilities were providing surgical care. Thus, the sample size for private hospitals was estimated to be 40. This makes a total of 203 study sites. Each hospital from each stratum was selected by a simple lottery method. However, due to internal conflict and limited transport accessibility in some parts of Ethiopia, we could not be able to access all health facilities that were selected randomly, and we decided to replace some health facilities which were convenient assuming that hospitals in the same strata are homogeneous. A total of 172 sampled health facilities were evaluated in the study, which hold 84.7% of the estimated sample size.

Routine DHIS 2 surgical care services database and pre-admission and admission register were reviewed using the Harvard Program in Global Surgery and Social Change and the WHO Surgical Assessment Tool [11], which was adopted in the context of Ethiopia. Thirteen trained data collectors reviewed the data from December 30, 2020-June 10, 2021. Data collectors were trained about the entire process of data collection including quality control measures such as: completeness, correctness, consistency, and synchronizing and archiving data with RedCap. The data we reviewed includes data dating back to September 2020 to May 2021; specifically, for total numbers of surgical procedures with the intention to capture the volume of procedures done in the past 90 days prior to data collection, therefore, this data reflects the volume of procedures done in a 90-day interval of the time from September 2020 to May 2021. Precaution measures including wearing a face mask, using hand sanitizers, and physical distancing were implemented to prevent Coronavirus disease 2019 (COVID-19) transmission during data collection.

To ensure the quality of data, the data were cleaned and checked for completeness, correctness, and consistency. Regular supervision and follow-up were made throughout the data collection period.

Surgical care: provision of perioperative and operative management for surgical conditions.

Surgical volume: number of minor and major surgical procedures performed during the study period.

Major surgery: surgeries that require general or regional anesthesia, involve opening great body cavities, have risk of severe hemorrhage, put the patient’s life at risk and needs postoperative care and require special anatomical knowledge, manipulative skills,and specific equipment.

Minor Surgery: surgeries in which short surgical techniques are applied on superficial tissues, usually with local anesthesia and minimal complications that usually do not require postoperative resuscitation and need minimal equipment.

A Bellwether procedure: any procedure involving laparotomy, cesarean section, or treatment of an open long bone fracture.

Physical access for surgical care: Surgical health facilities that can be accessed within two hours of travel.

Surgical referrals out: number of patients referred out of the hospitals/health center operation room (OR) blocks for surgical services after an on-site assessment by a medical professional in the reporting period.

Surgical workforce: total number of available surgical workforces including Surgeons (General, neurosurgeons, and orthopedic surgeons), Anesthesiologists or anesthesia care providers, Obstetrician-gynecologist, Integrated Emergency Surgical Officers (IESO), and Nurse Anesthetists.

The reviewed data were cleaned, checked for consistency, and entered into the Redcap database, and the data collectors archived cleaned data on a regular basis, every week. Then the cleaned data were exported into STATA Version 15 statistical software package for statistical analysis.

The study was approved by Armauer Hansen Research Institute (AHRI) ethical review board in Addis Ababa, Ethiopia. Additionally, the Ethiopia MOH issued a letter of support to conduct data review at the selected health facilities. Additionally, letters of support and permissions were obtained from the local health offices authorities to conduct data review at the selected health facilities.

A total of 172 health facilities were included in the study. Of which, 9 (5.2%), 77 (44.8%), 38 (22.1%), 16 (9.3%), and 32 (18.6%) were health center OR blocks, primary hospitals, general hospitals, specialized hospitals, and private hospitals, respectively.

Within a 90-day interval of the study period, from September 2020 through May 2021 a total of 69,717 major and minor surgical procedures were performed. Of which were 40, 202 (58%) major surgeries and 29,515 (42%) minor surgeries. With regard to the share of facilities, 40.7%, 27%, and 13.3% major procedures were performed at specialized, general, and primary hospitals, respectively. On the other hand, 20.5%, 23.1%, and 37.6% minor surgical procedures were undertaken in specialized, general, and primary hospitals, respectively. Private hospitals performed 18% of major and 16.4% of minor surgical procedures. One percent of major surgery (elective cesarean section) and 2.4% of minor surgeries were performed in health centers OR blocks (Table 1).

The study also showed that a total of 33,052 bellwether procedures were performed during the period. Public specialized hospitals performed 46.3% of Caesarean section, 34% of Laparotomies, and 49.4% of Open fracture managements. Private hospitals performed 11.2% of the total bellwether procedures including 33.4% of open fracture management, 21.3% of laparotomy, and 8% of caesarean section. About 12.8% and 3.1% of the bellwether procedures were performed at PHCUs (public primary hospitals and health center OR blocks), respectively (Table 2).

Comparing the median number of Caesarean section performed in public health facilities versus private hospitals, the median number of Caesarean section procedures performed in public health facilities was significantly different from the private hospitals; 67 (IQR:37–189) versus 48 (IQR: 24–81), respectively (Mann–Whitney test, P = 0.02). The median number of major surgical procedures that were performed in private hospitals was higher as compared to the number of procedures performed in public health facilities; 118 (IQR: 60–287) versus 93 (IQR: 36–214) (Mann–Whitney test, P = 0.16) (Table 3).

The overall median number of major surgical procedures that were performed in the surveyed public health facilities was 105 (IQR: 40–225). The median number of major surgical procedures performed in specialized hospitals, general hospitals, and PHCUs were 1028, 185, and 46, respectively (Kruskal–Wallis test; p < 0.001). The median number of Caesarean sections the surveyed public health facilities performed was 105 (IQR: 50–234). Specialized hospitals, general hospitals, and PHCUs reported 373, 165, and 46 median number of Caesarean section, respectively during the study period (Kruskal–Wallis test; p < 0.001) (Table 4).

Surgical volume to population ratio showed that on average, 289 surgical procedures were performed per 100,000 population in PHCUs within a 90-day interval of the study period. In specialized hospitals, the surgical volume to population ratio was found to be 33/100,000 population during the same period (Table 5).

The recorded average pre-admission waiting time for patients, who need essential surgical care in primary, general, and specialized hospitals was 9.68, 37.6, and 35.9 days, respectively. In private hospitals, the average pre-admission waiting time recorded for patients who need essential surgical care was 1.42 days. There was no essential surgical service in the health center OR blocks.

Data reviewed from the hospital pre-admission or admission register showed the average time that surgical patients needed to get to access surgical services in public specialized hospitals and private hospitals was 28 Hours (Hrs) and 21 Hrs, respectively. The time length required to get access to surgical care in primary hospitals was exceeded 4 hours (Table 6).

A total of 8,584 patients were referred for surgical services in a 90-day interval. About 3956 surgical patients were referred from PHCUs to other health facilities. Of these 3540 and 416 surgical patients were referred from public primary hospitals and health center OR blocks, respectively. Public generalized and public specialized hospitals referred 2936 and 1449 surgical patients, respectively. A total of 243 surgical cases were referred out to other health facilities from private hospitals during the same period (Fig. 1).

Lack of skilled professionals and equipment/instruments constitute 30% and 22% of the most common reasons for surgical referral out, respectively. Lack of supply/medication, lack of bed, lack of blood, patient preference, lack of investigation modalities, financial reasons, and lack of Intensive Care Unit (ICU) collectively account for nearly 50% of the reasons for referral out from the surveyed health facilities (Fig. 2).

A total of 2312 health workers were available for surgical care in the studied health facilities. About 51.14% of Surgeons (General, Neurosurgeons, and Orthopedic surgeons), 48.27% of Anesthesiologists or Anesthesia care providers, and 49.4% Obstetricians were available in public specialized hospitals. Fifty nine percent and 30.2% of Integrated Emergency Surgical Officers (IESO) were available in public primary and general hospitals, respectively (Table 7).

The ratio of surgical workforce served was 10.8/100,000 population in health center OR blocks, 7.5/100.000 population in primary hospital, 1.15/100,000 population in general hospital and 1.31/100,000 population in specialized hospital. This makes the average surgical work force in Ethiopia to be 5.19/100,000 population (Table 8).