Two-hour surgical access in South Africa: a useful indicator in a middle-income country?

Background In a robust health care system, at least 80% of a country’s population should be able to access a district hospital that provides surgical care within two hours. The objective was to identify the proportion of the population living within two hours of a district hospital with surgical capacity in South Africa. Methods All government hospitals in the country were identi�ed. Surgical district hospitals were de�ned as district hospitals with a surgical provider, a functional operating theatre


Background
The Lancet Commission on Global Surgery (LCGS) reported that ve billion people lack access to safe, timely, and affordable surgical care.In trying to de ne a minimum package of care for every health system, there are six indicators that are routinely measured (Table 1).The rst indicator is the proportion of a population that lives within two hours of a facility that provides the bellwether procedures (caesarean section, laparotomy, and treatment of an open fracture), which are used by the LCGS as a proxy for surgical capacity. 1 A recent modelling of two-hour access (2HA) in sub-Saharan Africa (SSA) demonstrated large inter-country variation (23 -97%).The 2HA in South Africa was estimated to be 95%, however, it did not consider the actual surgical capacity at each hospital.South Africa is an upper middle-income country with one of the most unequal income distributions in the world. 3Approximately 84% of the population relies on the public (government) health care system, 4 which is organized around primary health care clinics (PHC) and community health centers (CHC).PHC and CHC refer patients to district, then regional and tertiary hospitals for higher levels of care. 5The government surgical services are highly variable in terms of capacity and output and only employ 42% of general surgeons. 6While surgical care is a component of the Department of Health Strategic Plan, implementation strategies across different hospital levels are not well outlined. 7e World Health Organization stated that essential surgical care should be delivered at district hospitals (DH) which has been shown to be cost-effective. 8-12However, DH surgical capacity in many SSA countries remains unmeasured.
The objective of this study was to identify the proportion of the population living within two hours of a district hospital with surgical capacity in South Africa.
incorporating mesozones with population counts of less than ve people as mask areas, was used to estimate the proportion of the population residing within the 2HA service areas.

Results
There were 315 government hospitals in South Africa (75 tertiary/regional and 240 DHs).Ninety-eight percent of the population lived within 2 hours of one of these facilities.Although there were large areas of the country that did not have 2HA, these areas were sparsely populated covering only two percent of the population.Of all DH, 138 (58%) could be de ned as S-DH (DH with a functional operating room, a surgical provider, and performed at least one CS annually).The low and high estimates for 2HA to a S-DH were 86% and 89% respectively (Fig. 1).

Discussion
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 rst-referral (district) hospitals" in an unanimously passed declaration. 12Strengthening DH surgical capacity is an international mandate, and countries are tasked with formulating national surgical plans to improve access. 12The South African NDoH has de ned a DH surgical package but this has not been widely implemented. 15A has limitations as a metric of surgical access.Firstly, 2HA is challenging to measure due to the lack of available data.LCGS de nes 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. 16Therefore, 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 de nition for surgical capacity.
Secondly, the 2HA indicator does not consider other factors that impact access, such as the availability of transport or nancial 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. 17Furthermore, 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). 18Financial 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. 19ur study had methodologic limitations.The surgical capacity of a health facility is in uenced 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.

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Table 1 .
Global Surgery Indicators to Measure Universal Surgical Access 1CGS recommended six indicators to evaluate surgical delivery including 2HA.1This study demonstrated that in South Africa, more than 80% of the population could have 2HA to district hospitals with surgical capacity.However, this indicator as a global metric may not be practical given the lack of available country-level data on bellwether procedures16and because it does not measure other aspects of true access.Nevertheless, surgical access is a key component of surgical equity and nding improved ways to measure and achieve it must be a global health priority.Holmer H, Bekele A, Hagander L, Harrison EM, Kamali P, Ng-Kamstra JS, et al.Evaluating the collection, comparability and ndings of six global surgery indicators.Br J Surg 2019; 106 (2): e138-e150.17.Statistic South Africa.National Household Travel Survey.2013. 1 .Zaaijman JT.Rural district hospitals: ambulance services, staff attitudes, and other impediments to healthcare delivery.S Afr Med J 2015; 105 (12): 1001.19.Shrime MG, Dare AJ, Alkire BC, O'Neill K, Meara, JG.Catastrophic expenditure to pay for surgery worldwide: a modelling study.The Lancet Global Health 2015; 3 Suppl 2: S38-44.