Mapping population access to essential surgical care in Liberia using equipment, personnel, and bellwether capability standards

BACKGROUND: Accurate surveillance of population access to essential surgery is key for strategic healthcare planning. This study aimed to estimate population access to surgical facilities meeting standards for safe surgery equipment, specialized surgical personnel, and bellwether capability, cesarean delivery, emergency laparotomy, and long-bone fracture fixation and to evaluate the validity of using these standards to describe the full breadth of essential surgical care needs in Liberia. METHOD: An observational study of surgical facilities was conducted in Liberia between 20 September and 8 November 2018. Facility data were combined with geospatial data and analysed in an online visualization platform. RESULTS: Data were collected from 51 of 52 surgical facilities. Nationally, 52.9 per cent of the population (2 392 000 of 4 525 000 people) had 2-h access to their closest surgical facility, whereas 41.1 per cent (1 858 000 people) and 48.6 per cent (2 199 000 people) had 2-h access to a facility meeting the personnel and equipment standards respectively. Six facilities performed all bellwether procedures; 38.7 per cent of the population (1 751 000 people) had 2-h access to one of these facilities. Bellwether-capable facilities were more likely to perform other essential surgical procedures (OR 3.13, 95 per cent c.i. 1.28 to 7.65; P = 0.012). These facilities delivered a median of 13.0 (i.q.r. 11.3–16.5) additional essential procedures. CONCLUSION: Population access to essential surgery is limited in Liberia; strategies to reduce travel times ought to be part of healthcare policy. Policymakers should also be aware that bellwether capability might not be a valid proxy for the full breadth of essential surgical care in low-income settings.