First referral hospitals provide safe and effective surgery to more than 300 million people.
First referral hospitals provide safe and effective surgery to more than 300 million people.
Patients attending first referral hospitals in low- and middle-income countries (LMICs) receive surgical care that is just as safe and effective as that provided by higher level referral centres, a new study reveals.
Researchers found no significant difference in 30-day mortality rates between first referral, or district, hospitals and referral centres after adjusting for other factors. Similar rates of surgical site infections (SSI) were observed in both types of hospitals.
Backed by funding from the UK’s National Institute for Health and Care Research (NIHR), experts at the University of Birmingham led an international research team that analysed data from 15,657 patients across 80 hospitals in Benin, Ghana, India, Mexico, Nigeria, Rwanda and South Africa.
First referral hospitals are vital for delivering safe surgery to over 300 million people across the Global South. Our study challenges the common perception that surgical care in district hospitals is inherently riskier - providing evidence for policymakers working to achieve universal health coverage in resource-limited settings.
Publishing their findings in BMJ Global Health, the team reveals that, while first referral hospitals have fewer full-time surgeons and medically trained anaesthetists compared to referral centres (28.6% vs 87.1%), they manage to deliver safe surgical care.
Researchers discovered higher usage of the WHO Surgical Safety Checklist in first referral hospitals (99.4% vs 93.3%) and found that these facilities also perform a higher percentage of emergency surgeries (65.1% vs 56.6%).
Lead author Dr Sivesh Kathir Kamarajah, from the University of Birmingham, commented: “First referral hospitals are vital for delivering safe surgery to over 300 million people across the Global South. Our study challenges the common perception that surgical care in district hospitals is inherently riskier - providing evidence for policymakers working to achieve universal health coverage in resource-limited settings.
"We show that with proper support and resources, first referral hospitals can play a crucial role in expanding access to safe surgery in LMICs. There is huge potential for scaling up surgical capacity in first referral hospitals to meet global surgical needs.”
The study uses data from two high-quality randomised controlled trials undergoing major abdominal surgery - examining ways to reduce SSIs. FALCON and CHEETAH included children and adult patients undergoing elective or emergency surgery.
FALCON assessed whether a combination of four interventions for skin preparation and sutures before skin closure can significantly reduce SSIs compared with current practice. ChEETAh assessed whether routine changes of sterile gloves and instruments before abdominal wall closure significantly reduces SSIs.
Prioritising surgical and anaesthetic workforce remains on the core agenda of the Lancet Commission on Global Surgery to ensure equitable access to meet surgical needs and universal health coverage.
The researchers note that scaling up the surgical workforce to meet demands in first referral centres of LMICs is urgently needed, but a recent systematic review highlighted a need for randomised trials in this area.
There is also an urgent need safe training programmes for surgeons and anaesthetists – contextualised by country priorities – for example, hernia repairs are important in West Africa, whereas gallbladder disease is more prevalent in parts of India and South America.
“More research is needed to understand the wider referral pathway,” added Dr Kamarajah. “Ensuring appropriate referrals from primary care will prevent district hospitals from being overburdened, but these hospitals may be best placed to deliver simple emergency surgical care, close to the patient - freeing up referral hospitals to treat more complex cases.”
For more information or interview requests, please contact Tony Moran, International Communications Manager, University of Birmingham on +44 (0)782 783 2312. For out-of-hours enquiries, please call +44 (0) 121 414 2772.
The University of Birmingham is ranked amongst the world’s top 100 institutions, its work brings people from across the world to Birmingham, including researchers and teachers and more than 8,000 international students from over 150 countries.
‘Structures, processes and outcomes between first referral and referral hospitals in low-income and middle-income countries: a secondary preplanned analysis of the FALCON and ChEETAh randomised trials’ - NIHR Global Health Research Unit on Global Surgery is published in BMJ Global Health.
About the NIHR
The mission of the National Institute for Health and Care Research (NIHR) is to improve the health and wealth of the nation through research. We do this by:
NIHR is funded by the Department of Health and Social Care. Its work in low and middle income countries is principally funded through UK international development funding from the UK government.
NIHR Doctoral Fellow
Staff Profile for Sivesh Kamarajah, NIHR Doctoral Fellow in the Institute of Applied Health Research at the University of Birmingham.
