title: Who is performing surgery in low-income settings: a countrywide inventory of the surgical workforce distribution and scope of practice in Sierra Leone.
abstract: BACKGROUND
  Scope of practice and in-country distribution of surgical providers in low-income countries remains insufficiently described. Through a nationwide comprehensive inventory of surgical procedures and providers in Sierra Leone, we aimed to present the geographic distribution, medical training, and productivity of surgical providers in a low-income country.
  
  
  METHODS
  Following exhaustive sampling, a total of 60 facilities performing surgery in Sierra Leone 2012 was identified. Annual surgical activity was obtained from 58 (97%) facilities, while institution and workforce data was retrieved from 56 (93%). Characteristics of patients, facilities, procedures, and surgical providers were collected retrospectively from operation theatre logbooks and by interviewing facility directors.
  
  
  RESULTS
  In 2012, 164 full-time positions of surgical providers performed 24 152 surgeries in Sierra Leone. Of those, 58 (35·6%) were consultant surgeons, obstetricians, or gynaecologists (population density: 0·97 per 100 000 inhabitants). 86 (52·9%) were medical doctors (1·42 per 100 000), whereas the 14 (8·4%) associate clinicians and six (3·8%) nurses represented a density of 0·23 and 0·10 per 100 000 inhabitants, respectively. Almost half of the districts (46%), representing more than 2 million people (34% of the population), had less than one fully trained consultant. Density of consultant and medical doctors were 27 and six times higher in urban areas compared with rural areas, respectively. The surgical providers performed 144 surgeries per position in 2012 (2·8 surgeries per week). Nurses performed 6·6% and associate clinicians 6·8% of the total national volume of surgeries. Districts with lower surgical rates had a significant lower productivity per surgical provider (Rho=0·650, p=0·022). We noted a significant positive correlation between the facility volume of surgery and the productivity of each surgical provider (p<0·001).
  
  
  CONCLUSIONS
  Surgical providers with higher qualifications seem to have a preference for urban settlements. Increasing the output of the existing workforce can contribute to expansion of surgical services.
  
  
  BACKGROUND
  Norwegian University of Science and Technology.
authors: Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; CapaCare, Trondheim, Norway; Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway. Electronic address: hakon.bolkan@capacare.org.
authors: Håkon A
authors: HA
authors: Bolkan
authors: Department of Clinical Sciences, Paediatric Surgery and Global Paediatrics, Faculty of Medicine, Lund University, Children's Hospital, Lund, Sweden.
authors: Lars
authors: L
authors: Hagander
authors: Health System and Policy Research Group, Karolinska Institutet, Stockholm, Sweden.
authors: Johan
authors: J
authors: von Schreeb
authors: Ministry of Health and Sanitation, Freetown, Sierra Leone.
authors: Donald
authors: D
authors: Bash-Taqi
authors: Department of Surgery, Connaught Hospital, Freetown, Sierra Leone.
authors: Thaim B
authors: TB
authors: Kamara
authors: Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
authors: Øyvind
authors: Ø
authors: Salvesen
authors: Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; CapaCare, Trondheim, Norway; Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
authors: Arne
authors: A
authors: Wibe