Publishing their findings in BMJ Global Health, the team reveals that while primary referral hospitals have fewer full-time surgeons and medically trained anesthetists compared to referral centers (28.6% vs. 87.1%), they succeed in delivering safe surgical care.

Researchers found higher use of the WHO surgical safety checklist in first-referral hospitals (99.4% vs. 93.3%) and found that these facilities also perform a higher proportion of emergency surgeries (65.1% vs. 56.6%).

Lead author Dr Sivesh Kathir Kamarajah, from the University of Birmingham, commented: “First referral hospitals are critical to 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 – provides evidence for policy makers working to achieve universal health coverage in resource-limited settings.

“We show that with the right support and resources, primary referral hospitals can play a critical role in expanding access to safe surgery in LMICs. There is enormous potential to scale up surgical capacity at primary referral hospitals to meet global surgical needs.”

The study uses data from two high-quality randomized controlled trials undergoing major abdominal surgery – investigating ways to reduce SSIs. FALCON and CHEETAH included children and adult patients undergoing elective or emergency surgery.

FALCON assessed whether a combination of four procedures for skin preparation and sutures prior to skin closure can significantly reduce SSI compared to current practice. ChEETAh assessed whether routine changes of sterile gloves and instruments prior to abdominal wall closure significantly reduce SSI.

Prioritization of surgical and anesthesia workers 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 there is an urgency to scale up the surgical workforce to meet the demands of first referral centers of LMICs, but a recent systematic review indicated a need for randomized trials in this area.

There is also an urgent need for safe training programs for surgeons and anesthetists – contextualised by the country’s priorities – for example, hernia repairs are important in West Africa, while gallbladder surgery is more common in parts of India and South America.

“More research is needed to understand the wider referral pathway,” Dr Kamarajah added. “Ensuring appropriate referrals from primary care will prevent district hospitals from becoming overburdened, but these hospitals may be best suited to provide simple acute surgical care, close to the patient – freeing up referral hospitals to treat more complex cases.”