Major and minor surgery output at district level in Kenya: review and issues in need of further research

Abstract

Major and minor surgery is a service of great importance both for the people in need and for health workers and managers trying to develop a comprehensive primary health care service. While in highly industrialised countries some 5000 - 9000 major operations are performed per 100,000 people per year, the rates in East Africa in the early 1990s were in the range of 70-500. In our study all surgical operations performed at hospitals and clinics in Meru district during 12 months in 1990-1991 were listed on record forms including age, sex and home address of patients, and type of operation. Totally 3,415 major operations were recorded, corresponding to 263/100,000 people (88 for males and 434 for females), and the most common major operations were caesarean section, tubal ligation, explorative laparotomy, eye/lens removal and hernia repair. Assuming that the basic need in eastern Africa is about 1,000 major operations/100,000/year it appears that only 7-50% of this basic need was available in this rural area. The epidemiological basis for such estimates is however rather weak and the information systems are unsatisfactory. More accurate data are required both on descriptive epidemiology and on surgical service output as a basis for planning. Comparisons are difficult due to poorly standardised epidemiology and output indicators. We examine, from a health planning perspective, four possible methods of quantifying the major surgery output: (a) the annual number of major operations per 100 hospitals beds; (b) the number per 1000 inpatient admissions; (c) the number per 10,000 new out-patient consultations; and (d) the annual number per 100,000 catchment area population. The mean number per 100 beds was 310 with a range from 452 to 140; the mean number per 1000 admissions was 74 ranging from 88 to 31, the number per 10,000 new outpatient visits was 96 ranging from 188 to 55, and the mean number per 100,000 catchment area population was 263 for the entire district with a range from 383 to 119 among the five hospitals. We conclude that option (1) and (2) are useful and implementable, (3) is less useful but implementable, and option (4) is potentially very useful but not easily implementable until a catchment area population definition is agreed. Minor surgery is even less well investigated, and there are hardly any studies at all from low-income countries. Our data from Meru demonstrate that the one-year output in a population of 1.3 million people was 26,858 (2,066/100,000 people/year) of which about 82% were done at the hospitals in the area. The smaller clinics did on average only 1.8-6.4 minor operations per month. The basic need for minor surgery in these areas has not been estimated, so the unmet need must be considered unknown. Further research is recommended in the following areas: epidemiological estimates of surgical service need in eastern Africa, critical review of the health information systems with regard to surgery, quality of major and minor surgery services especially in rural areas, reasons for low surgical output at small clinics; possible remedies.
[Afr. J. Health Sci. 2002; 9: 17-25 ]