Who is performing surgery in low-income settings: a countrywide inventory of the surgical workforce distribution and scope of practice in Sierra Leone.

Background: Scope of practice and in-country distribution of surgical providers in low-income countries remains insufficiently described. Through a nationwide comprehensive inventory of surgical procedures and providers in Sierra Leone, we aimed to present the geographic distribution, medical training, and productivity of surgical providers in a low-income country.

Methods: Following exhaustive sampling, a total of 60 facilities performing surgery in Sierra Leone 2012 was identified. Annual surgical activity was obtained from 58 (97%) facilities, while institution and workforce data was retrieved from 56 (93%). Characteristics of patients, facilities, procedures, and surgical providers were collected retrospectively from operation theatre logbooks and by interviewing facility directors.

Findings: In 2012, 164 full-time positions of surgical providers performed 24 152 surgeries in Sierra Leone. Of those, 58 (35·6%) were consultant surgeons, obstetricians, or gynaecologists (population density: 0·97 per 100 000 inhabitants). 86 (52·9%) were medical doctors (1·42 per 100 000), whereas the 14 (8·4%) associate clinicians and six (3·8%) nurses represented a density of 0·23 and 0·10 per 100 000 inhabitants, respectively. Almost half of the districts (46%), representing more than 2 million people (34% of the population), had less than one fully trained consultant. Density of consultant and medical doctors were 27 and six times higher in urban areas compared with rural areas, respectively. The surgical providers performed 144 surgeries per position in 2012 (2·8 surgeries per week). Nurses performed 6·6% and associate clinicians 6·8% of the total national volume of surgeries. Districts with lower surgical rates had a significant lower productivity per surgical provider (Rho=0·650, p=0·022). We noted a significant positive correlation between the facility volume of surgery and the productivity of each surgical provider (p<0·001).

Interpretation: Surgical providers with higher qualifications seem to have a preference for urban settlements. Increasing the output of the existing workforce can contribute to expansion of surgical services.

Funding: Norwegian University of Science and Technology.