A prospective study of the factors affecting access to equitable surgical care in the Southern Province of Rwanda

Background
Access to equitable surgical care significantly reduces morbidity and mortality from traumatic injuries, abdominal, extra-abdominal, acquired and congenital conditions. In Rwanda, like many other developing countries, there are is a wide range of factors affecting access to surgical care across the different levels of health care delivery. The main objective of this study was to document the factors affecting access to surgical care in the Southern Province of Rwanda.
Methods
This prospective observational study randomly selected 5 of the 11 district hospitals in the province. The other health unit included was the regional referral hospital for the province, Butare (CHUB). The variables tested included surgical capacity, timeliness, safety, and affordability, for all the included health units in the province. The lists of elective surgical patients, compared with the lists of operated patients over a period of six months, were used to indicate the performance and outputs to surgical access for the various health units in this study. In addition, 5 patient interviews were conducted at each health unit, from patients who were randomly selected, from both the surgical outpatients and the surgical wards. They were questioned regarding their views to surgical care access. Percentages were used to indicate the extent of the challenges to surgical access.
Results
The lack of adequate surgical staff was the commonest challenge to surgical access (75% for the district hospitals, and10% for the regional referral hospital) identified. At the regional referral hospital (CHUB), limited operating theatre space was a challenge in 50% of the cases. This was followed by the limited number of specialists and sub-specialties rated at 10%, and limited anesthetic plus ICU facilities rated at 10%. The other challenge was the issue of affordability for the consumables required, rated at 10% The average surgical output and the pending (representing unmet need), calculated from the elective waiting lists for a period of 6 months, indicated that the number of operated patients were rated at 75% , and an unmet need of surgical access of 25% for CHUB; while for the district hospitals it was 63% with an unmet need of 37%.The patients’ views also pointed at challenges of limited surgical services at the district hospital (70%), and affordability (30%).
Conclusions
Access to surgical care in the Southern Province of Rwanda was affected by the limited number of specialists and doctors with the minimum skills to carry out non-specialized operations at the district hospitals, the limited operating theatre facilities, limited sub-specialist services, and specialized investigations.

Keywords
surgical care; access; challenges; capacity; safety; affordability; timing