“The buck stops here”: Experiences of frontline healthcare workers in expanding district hospital surgical services in rural South Africa
1
Division of Global Surgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A1777
ABSTRACT
BACKGROUND:
Approximately one-third of the global burden of disease is attributable to surgical conditions, yet five billion people lack access to emergency and essential surgical care1. District hospitals are strategically positioned to address this gap, but their capacity to deliver surgical services is highly variable2. While the challenges are well described, little is known from rural facilities which have successfully expanded surgical services.
AIM:
This study explored the experiences of frontline healthcare workers at a rural district hospital in South Africa that expanded its surgical services, with the aim of generating contextually grounded insights to inform policy, funding, and future capacity-building initiatives.
METHODS:
We conducted an exploratory qualitative study using a phenomenological approach at Madwaleni District Hospital, Eastern Cape. Fifteen purposively sampled participants took part in semi-structured interviews. Data were analysed using a hybrid inductive–deductive approach and mapped to the Extended Normalization Process Theory framework.
RESULTS:
Participants described a system where surgical expansion was technically feasible but constrained by fragile infrastructure, staffing shortages, and weak pre- and post-operative systems. Strong relational networks, mentorship, and academic partnerships enabled service growth despite limited material capacity. Expansion was driven primarily by individual intrinsic motivation, and a perceived moral imperative to meet community needs, summarised by one clinician as “the buck stops here.” The reliance on individual champions was perceived to create service fragility, result in emotional fatigue, and risk sustainability in the absence of formal mandates or protected resources.
CONCLUSIONS:
Successful surgical expansion at rural district hospitals is feasible with motivated and skilled frontline health workers operating within supportive relational ecosystems, even in settings without policy directive. Equitable surgical systems will require policymakers to empower frontline healthcare workers to innovate locally, harnessing their potential and capability, whilst also strengthening the health system with protected resources, training pathways, and systems of support.
Approximately one-third of the global burden of disease is attributable to surgical conditions, yet five billion people lack access to emergency and essential surgical care1. District hospitals are strategically positioned to address this gap, but their capacity to deliver surgical services is highly variable2. While the challenges are well described, little is known from rural facilities which have successfully expanded surgical services.
AIM:
This study explored the experiences of frontline healthcare workers at a rural district hospital in South Africa that expanded its surgical services, with the aim of generating contextually grounded insights to inform policy, funding, and future capacity-building initiatives.
METHODS:
We conducted an exploratory qualitative study using a phenomenological approach at Madwaleni District Hospital, Eastern Cape. Fifteen purposively sampled participants took part in semi-structured interviews. Data were analysed using a hybrid inductive–deductive approach and mapped to the Extended Normalization Process Theory framework.
RESULTS:
Participants described a system where surgical expansion was technically feasible but constrained by fragile infrastructure, staffing shortages, and weak pre- and post-operative systems. Strong relational networks, mentorship, and academic partnerships enabled service growth despite limited material capacity. Expansion was driven primarily by individual intrinsic motivation, and a perceived moral imperative to meet community needs, summarised by one clinician as “the buck stops here.” The reliance on individual champions was perceived to create service fragility, result in emotional fatigue, and risk sustainability in the absence of formal mandates or protected resources.
CONCLUSIONS:
Successful surgical expansion at rural district hospitals is feasible with motivated and skilled frontline health workers operating within supportive relational ecosystems, even in settings without policy directive. Equitable surgical systems will require policymakers to empower frontline healthcare workers to innovate locally, harnessing their potential and capability, whilst also strengthening the health system with protected resources, training pathways, and systems of support.
| eISSN: | 2654-1459 |
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