The State of Surgery in Botswana, 2018 to 2022.

Many people living in low-income and middle-income countries (LMICs) lack access to safe surgical and anesthetic care. The Lancet Commission on Global Surgery (LCGS) recommended that all countries track surgical volume and target 5,000 procedures per 100,000 population. While some LMICs report operative volume, case distribution, and surgical capacity, little is known about these metrics in Botswana. The present study addresses this gap by examining trends across multiple surgical disciplines in Botswana over a 5-year period. All surgical procedures that took place from 2018 to 2022 across 6 geographically diverse hospitals throughout Botswana were extracted from on-site logbooks. Population estimates were used to calculate operative volume and assess trends. The total number of procedures performed per 100,000 population increased from 2018 to 2021 (2018: 404, 2019: 416, 2020: 415, 2021: 448) but decreased in 2022 (346). Most operations were performed by obstetricians/gynecologists (22,179, 43.0%) and general/thoracic surgeons (13,866, 26.9%). Plastic surgeons performed 0.6% (n=309) of cases, most commonly skin grafting (41.4%, n=128), breast reduction (17.5%, n=54), and wound debridement (15.9%, n=49). The proportion of elective procedures increased from 2018 (32.5%) to 2022 (76.2%), (r=0.088, P =0.048*). The number of laparoscopic procedures and procedures performed by surgical subspecialists also increased, but failed to reach significance ( P >0.05). Surgical capacity in Botswana is growing, but remains significantly below LCGS targets. Trends in elective surgery, laparoscopic procedures, and subspeciality care suggest advances in surgical care. Continued investment in surgical infrastructure and workforce development is essential to further enhance surgical capacity in Botswana.