The contribution of first-level hospitals to 6 essential surgical procedures in a South African health district: A retrospective, cross-sectional study

  • Kathryn Chu
  • Megan Naidoo
  • Juan H. Klopper
  • J. Christo Kloppers
  • Pradeep Navsaria
  • Anthony Reed
Keywords: global surgery, first-level hospitals, essential surgery, South Africa


Background: Decentralization of surgical services to first-level hospitals is an essential step towards achieving universal health coverage. However, the surgical capacity of first-level hospitals can vary greatly, with some having limited or no surgical capacity. This study aimed to identify the proportion of 6 essential operations performed at each hospital level within a South African health district, with a focus on the contribution of first-level hospitals as a proxy for their surgical capacity.

MethodsThis was a cross-sectional study conducted in the Cape Metro West health district in Cape Town, South Africa. The number and volume of 6 essential operations: abscess drainage, appendectomy, hernia repair, cholecystectomy, emergency laparotomy, and lower extremity amputation, were described from 1 April 2015 through 31 March 2016 at 7 government hospitals. First-level hospitals were stratified into large metropolitan facilities and small facilities.

Results: The majority of the 6 essential operations were performed at large metropolitan first-level hospitals (48.4%), while small first-level hospitals performed only 11 operations (0.2%), conducting no appendectomies, cholecystectomies, or lower extremity amputations during the study period. Second- and third-level hospitals conducted close to one-fifth (18.6%) and one-third (32.9%) of these procedures, respectively.

Conclusions: While the majority of “first-level” essential operations were performed at large metropolitan first-level hospitals, smaller first-level hospitals performed very few of the selected essential operations. In contrast, third-level hospitals conducted one-third of these procedures, which limits resources for more complex surgical conditions. There is an urgent need to upskill nonspecialists and address other barriers to increasing surgical capacity at smaller first-level hospitals.

Original Research