Operative volume and surgical case distribution in Uganda's public sector: a stratified randomized evaluation of nationwide surgical capacity

BackgroundLittle is known about operative volume, distribution of cases, or capacity of the public sector to deliver essential surgical services in Uganda.MethodsA standardized mixed-methods surgical assessment and retrospective operative logbook review were completed at 16 randomly selected public hospitals serving 640% of Uganda's population.ResultsA total of 3014 operations were recorded, annualizing to a surgical volume of 36,670 cases/year or 1445 operations/100,000people/year. Absolute surgical volume was greater at regional referral than general hospitals (p<0001); but, relative surgical volume/catchment population was greater at the general versus regional level (p=003). Most patients undergoing operations were women (783%) with a mean age of 269years. The overall case distribution was 690% obstetrics/gynecology, 237% general surgery, 40% orthopedics, and 33% other subspecialties. Cesarean sections were the most common operation (558%). Monthly operative volume was strongly predicted by number of surgical, anesthetic, and obstetric physician providers (?=1072, p=0005, R-2=094) when controlling for confounders. Notably, operative volume was not correlated with availability of electricity, oxygen, light source, suction, blood, instruments, suture, gloves, intravenous fluid, or antibiotics.ConclusionAn understanding of operative case volume and distribution is essential in facilitating targeted interventions to strengthen surgical capacity. These data suggest that surgical workforce is the critical driver of operative volume in the Ugandan public sector. Investment in the surgical workforce is imperative to ensure access to safe, timely, and affordable surgical and anaesthesia care.