Background: Most quality improvement (QI) activities in developing countries, established with funds from external donors, are focused on specific diseases or outreach programs, such as family planning or child survival. District hospitals in developing countries serve as the primary entry point for patients with surgical problems in developing countries, yet little is known about the extent to which formal QI activities for surgical services are present in these settings or the perceptions of hospital staff about the barriers to improving quality in this setting. This study aimed to document surgical QI efforts at district hospitals and perceived barriers to improving quality in a developing country - Ghana. It also provides a summary of the existing published scientific literature concerning surgical QI in developing countries. Methods: A survey team visited 10 government district hospitals in Ghana, one in each of Ghana's 10 regions. The number and type of QI activities (surgical and nonsurgical) at these district hospitals and the perspectives of hospital staff regarding the steps required to improve the quality of surgical services in their facility were recorded. Results: Of the 10 hospitals assessed, nine reported having some type of QI activity, ranging from satisfaction surveys to assessing quality of infection prevention. Only one hospital reported having QI activity addressing surgical care. To improve the quality of surgical care, seven hospitals reported the need for trained specialists in surgery, obstetrics, and gynecology. Six cited the need for an appropriately equipped operating theater and recovery ward. The primary barrier to achieving these recommendations, cited by 70 % of the hospitals, was the inability to recruit and retain qualified specialists with surgical skills. Conclusions: For Ghana to improve significantly the quality of surgical care provided in its district hospitals, greater emphasis is needed for continuous, systematic QI monitoring and for solving the problems identified. Increasing the number of appropriately trained surgical care providers is essential to strengthen the quality of surgical services in district hospitals. These findings likely apply to other resource-limited countries as well. Increased attention to improving the quality of surgical services at district hospitals in developing countries is urgently needed.
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