Barriers to Performing Essential Surgery at First-Level Hospitals in Pakistan: A Mixed Methods Study.

Introduction: There are numerous reasons for underutilization of the public health sector for surgery in Pakistan. This results in patients being diverted to private hospitals or tertiary care centers in urban areas. Diversions overburden the hospitals and significantly increase out-of-pocket costs for the patients. This study aims to determine the barriers to surgical care in first-level hospitals in Pakistan's Sindh province.

Methods: We conducted a concurrent nested mixed methods study from May to June 2021 in public sector first-level hospitals in the Sindh province. Fifteen hospitals in six districts were surveyed. A consolidated hospital assessment tool adapted from the World Health Organization's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used for quantitative data collection. Interview guides were developed for staff interviews.

Results: Availability of trained staff was found to be the biggest barrier to the provision of safe surgery. Only eight hospitals had a general surgeon, anesthesiologist, and obstetrician/gynecologist, while the remaining had 1-2 of the three disciplines. Thirteen hospitals had a functioning x-ray machine, while 14 facilities had functioning ultrasound machines with trained personnel to operate them. Only three facilities always had blood available for transfusion. The qualitative component corroborated that the biggest barrier to providing surgical care was the lack of human resources.

Conclusions: The lack of human resources is difficult to overcome. We found evidence of task-shifting to medical officers and trainee anesthesiologists, but this is without discrete regulation and monitoring. Building surgical workforce capacity must be addressed in the interest of quality care.