Essential Surgery Delivery in the Northern Kivu Province of the Democratic Republic of the Congo

Introduction: Essential surgical services are a critical component of any functional healthcare system, though this capacity is not known in many low- and middle-income countries (LMICs) including the Democratic Republic of Congo (DRC). Methods: Hospitals were assessed in the North Kivu province of the DRC. Hospital characteristics and surgical rates were determined using the WHO-PGSSC hospital assessment tool and operating room (OR) registries. Primary predictors were the number of trained surgeons, anaesthesiologists, and obstetricians (SAOs) and the number of perioperative providers (including clinical officers and nurse anaesthetists) per 100,000 people. The primary outcome of interest was the number of Bellwether operations (i.e. Caesarean sections, laparotomies, and external fixation for bone fractures) per 100,000 people. Univariate and multivariate linear regressions were performed. Results: : Twenty-eight hospital facilities were assessed over the course of 2021; 24 (86%) were first-level referral health centres while 4 (14%) were second-level referral hospitals. In total, 11,176 Bellwether procedures were performed in the region. Rates per 100,000 people were 1,461 Bellwether surgical interventions, 1.05 SAOs, and 13.1 perioperative providers. In univariate analysis, each additional SAO added 239 additional cases annually (p=0.023), while each additional perioperative provider added 110 cases annually (p<0.001). After adjusting for other hospital services, the association between workforce and Bellwether surgeries was no longer significant (p=0.322). Conclusions: Delivery of essential surgery is lower in the current DRC study compared to other African settings. Major investments are needed to alleviate pre-hospital barriers in basic healthcare facilities and increase surgical workforce training.