Patients attending first referral hospitals in low- and middle-income countries (LMICs) receive surgical care that is just as safe and effective as that provided by higher level referral centers, reveals a new study in BMJ Global Health,

Researchers found no significant difference in 30-day mortality rates between first referral (district) hospitals and referral centers after adjusting for other factors. Similar rates of surgical site infections (SSI) were observed in both types of hospitals.

Researchers at the University of Birmingham led an international research team that analyzed data from 15,657 patients across 80 hospitals in Benin, Ghana, India, Mexico, Nigeria, Rwanda and South Africa.

The team reveals that while first referral hospitals have fewer full-time surgeons and medically trained anesthetists compared to referral centers (28.6% vs. 87.1%), they manage to deliver safe surgical care.

Researchers discovered higher usage of the WHO Surgical Safety Checklist in first referral hospitals (99.4% vs. 93.3%) and found that these facilities also perform a higher percentage of emergency surgeries (65.1% vs. 56.6%).

Lead author Dr. Sivesh Kathir Kamarajah, from the University of Birmingham, commented, “First referral hospitals are vital for 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—providing evidence for policymakers working to achieve universal health coverage in resource-limited settings.

“We show that with proper support and resources, first referral hospitals can play a crucial role in expanding access to safe surgery in LMICs. There is huge potential for scaling up surgical capacity in first referral hospitals to meet global surgical needs.”

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

FALCON assessed whether a combination of four interventions for skin preparation and sutures before skin closure can significantly reduce SSIs compared with current practice. CHEETAh assessed whether routine changes of sterile gloves and instruments before abdominal wall closure significantly reduces SSIs.

Prioritizing the surgical and anesthetic workforce 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 scaling up the surgical workforce to meet demands in first referral centers of LMICs is urgently needed, but a recent systematic review highlighted a need for randomized trials in this area.

There is also an urgent need for safe training programs for surgeons and anesthetists—contextualized by country priorities—for example, hernia repairs are important in West Africa, whereas gallbladder disease is more prevalent in parts of India and South America.

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