Assessment of Surgical Care Capacity at Non-Tertiary Hospitals in Botswana 

Mpapho Joseph Motsumi1, Nkhabe Chinyepi2, Kagelelo Difela2, Karabo Ngwako2, Maranatha Sentsho2, Unami Chilisa2, Tefo Leshomo2 

1Faculty of Medicine, Sir Ketumile Masire Teaching Hospital, University of Botswana, Gaborone, Botswana
2Department of Surgery, Faculty of Medicine, University of Botswana, Gaborone, Botswana


Correspondences to: Mpapho Joseph Motsumi; email:

Received: 2 Mar 2022; Revised: 9 Aug 2022; Accepted: 10 Aug 2022; Available online: 24 Aug 2022



Most low- and middle-income communities (LMICs) live in rural areas and are served mainly by primary and district hospitals. This study seeks to geographically map these hospitals and measure their surgical care capacity in Botswana. 

Materials and methods

This 3-month cross-sectional observational study was conducted at the Department of Surgery, University of Botswana. Google Map was used to map hospitals geographically. The PIPES (personnel, infrastructure, procedures, equipment, and supplies) tool was used to assess the surgical care capacity of hospitals. This tool was developed by Surgeons Overseas to quantify surgical capacity in low-resource settings. Consent was obtained. 


Nine districts and ten primary hospitals were assessed. The distance from settlements to the nearest healthcare facility in sparsely populated areas was relatively larger, making timely healthcare access potentially problematic. Intensive care services were unavailable except at three hospitals. None of the hospitals had full blood bank services. X-ray and ultrasound machines and basic supplies were available at over 90% of the hospitals. 


There was a general lack of surgical care specialists. Hospitals with a full complement of surgical care specialists had relatively higher PIPES indices. We recommend investing in deploying specialized surgical care providers to primary and district hospitals.

Key words: Surgical care capacity; Non-tertiary hospital; Surgical services 

Ann Afr Surg. 2022; 19(4): 193-199


Conflicts of Interest: None

Funding: None

© 2022 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.


The vision of the Lancet Commission on Global Surgery is universal access to safe and affordable surgical and anesthesia care when needed (1). Good health systems are rooted in the communities they serve (2). This removes the common hurdles that exclude the poor and marginalized from the needed surgical care, especially those living in rural areas (1). Most communities in low- and middle-income countries (LMICs) live in rural areas (3). District hospitals, also often referred to as regional hospitals, are vital to surgical care delivery to the local communities in LMICs (4). However, many of these district hospitals are unable to deliver essential surgical services (4, 5). Strengthening the surgical care capacity of these hospitals would improve the delivery of essential surgical services to communities in rural areas (4). LMICs need to carry out local situational assessments to guide their efforts toward improving the delivery of essential surgical care by district hospitals, which serve most rural communities.
National surgical health policies must be driven by local and context-specific data generated through local research (6). Therefore, the continuous assessment of barriers to delivering essential surgical care services at district hospitals is paramount. Findings from such assessments will provide feedback to policymakers and direct their efforts (6). This is especially relevant in LMICs, like Botswana, which is most hit by the failure to deliver timely and readily accessible surgical care to their communities.
Botswana is a high middle-income country with a population estimated at 2 million. Gaborone is the capital city of the country. There are three levels of hospitals in Botswana: referral (tertiary), district, and primary hospitals, in the order of their capacity to deliver healthcare services. The Ministry of Health for Botswana provides the following definitions of levels of hospitals. Primary hospitals are general hospitals that are equipped to deal with most diseases, injuries, and immediate threats to health. District hospitals are major district health facilities equipped with a larger number of beds capable of dealing with intensive and long-term care. Finally, referral hospitals and health facilities are equipped to deal with specialized diseases, medical needs, and care (7).
Most of the primary hospitals were built with the capacity to be upgraded to the district hospital level structurally. This study seeks to provide a geographic map of most primary- and district-level hospitals in Botswana and assess their surgical care capacity. The geographic mapping of these hospitals aims to give a quick visual appreciation of their distribution countrywide. The distance to a healthcare facility in a community is a critical factor in surgical care that is accessible when and where it is needed (8). The assumption is that the findings will be relevant to other LMICs and add to the growing but limited body of literature on the subject (9).


Materials and Methods

This is a cross-sectional, observational study conducted over 3 months at the department of surgery, University of Botswana. 

Figure 1. Distribution of hospitals within the ten districts in Botswana.

Botswana is geographically divided into ten districts, as demonstrated in Figure 1. The country’s north- and south-eastern band is relatively populous and more developed. The distribution of hospitals is geographically skewed toward this geographic band. Figure 1 shows the geographic distribution of hospitals in Botswana. There are three fully operational tertiary hospitals which ar