A Practical Method To Evaluate Surgical Access In Low-middle Income Countries

Introduction: Access and availability of timely, quality surgical services remain a problem in low-middle income countries. Easily obtainable measures such as the facilities caesarian section ratio and whether a facility can complete and care for a patient undergoing a damage control laparotomy, are needed to evaluate access to surgical services. This current study aims to evaluate surgical access and resources allocation at primary, district, and tertiary level facilities (public and private) throughout Botswana. These data have the potential to help guide future surgical resource allocation in other low-middle income countries throughout the world. Methods: Caesarian section ratio was calculated based on the ratio of caesarian sections to total surgical procedures completed during the data collection timeframe (June 2022 - June 2023). Total surgical procedures included all procedures performed in an operating theater requiring local, general, spinal, or regional anesthesia. Data was collected from a selection of primary, district, and tertiary facilities throughout Botswana. Results: A total of 7 primary, 3 district, and 2 tertiary facilities were included. Most facilities (10/12) were public. More surgical procedures were completed at tertiary compared to primary and district level facilities, 4889 (555) vs 379 (368); mean (SD), respectively. Tertiary facilities had lower caesarian section ratios than primary and district level facilities, 19 (17) v 64 (27); mean (SD). Private facilities had lower caesarian section ratios than public facilities, 13 (10) v 65 (25); mean (SD). Only tertiary level facilities were able to complete damage control laparotomies. Conclusion: The caesarian section ratio can be easily obtained and dynamically followed to provide feedback on surgical resource utilization. The high caesarian section ratio seen in public facilities demonstrates an unmet surgical need, with resources asymmetrically devoted to perinatal care. Tertiary level facilities can complete damage control laparotomies, showing that surgical resources are available in Botswana.