In South Africa, an upper middle-income country, the majority of the population lived less than two hours away from a district hospital with surgical capacity, exceeding the LCGS target of 80%.1 However, almost half of district hospitals did not have surgical capacity. The World Health Assembly urged members to incorporate essential and emergency surgical care into universal health coverage, including integration “in primary health care facilities and first- referral (district) hospitals” in an unanimously passed declaration.12 Strengthening DH surgical capacity is an international mandate, and countries are tasked with formulating national surgical plans to improve access.12 The South African NDoH has defined a DH surgical package but this has not been widely implemented.15
2HA has limitations as a metric of surgical access. Firstly, 2HA is challenging to measure due to the lack of available data. LCGS defines 2HA as proximity to a hospital that performs the bellwether procedures. In many countries, including South Africa, most hospitals do not provide granular data on these operations. In a recent study, data to measure this metric were available for only 19 countries and of these, only 2 were in SSA.16 Therefore, in order to estimate 2HA in South Africa, we used the presence of a functional operating theatre, a surgical provider, and provision of at least one CS annually as a proxy definition for surgical capacity.
Secondly, the 2HA indicator does not consider other factors that impact access, such as the availability of transport or financial constraints. For example, only 29% of households in South Africa have private cars and public transport is not reliable in every part of the country.17 Furthermore, ambulances are not readily available and may not respond within the two-hour access window. In the rural area of Eastern Cape, there is a severe shortage of pre-hospital emergency medical services with only 12 ambulances for a population of 1 million (the recommendation is one per 10,000 persons).18 Financial costs can limit access to- and utilization of- health services. A recent modelling study demonstrated that combined direct medical and non-medical costs would potentially be catastrophic for up to half of the global population.19
Our study had methodologic limitations. The surgical capacity of a health facility is influenced by human resource, equipment, and implementation challenges, such as theatre/post-operative personnel and surgical materials, which our study did not measure. An in-depth situational analysis into the various barriers to strengthening surgical capacity and outputs at South Africans DHs is necessary.