Editor’s note: This executive summary of The Lancet Commission on Global Surgery was published online on April 27, 2015, by The Lancet.* It has been edited here to conform with Bulletin style and is reprinted with permission from Elsevier. The full report can be accessed at The Lancet.
Remarkable gains have been made in global health in the last 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, lifesaving surgical and anesthesia care in low- and middle-income countries (LMICs)† has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treated conditions, including appendicitis, hernia, fractures, obstructed labor, congenital anomalies, and breast and cervical cancer.
Global health burdens
In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, non-communicable diseases, and injuries. Surgical and anesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anesthesia care, which should be available, affordable, timely, and safe to ensure good coverage, uptake, and outcomes.
Despite growing need, the development and delivery of surgical and anesthesia care in LMICs has been nearly absent from the global health discourse. Little has been written about the human and economic effect of surgical conditions, the state of surgical care, or the potential strategies for scale-up of surgical services in LMICs. To begin to address these crucial gaps in knowledge, policy, and action, The Lancet Commission on Global Surgery (LCoGS) was launched in January 2014. The commission brought together an international, multidisciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents.
Five key messages
The LCoGS formed four working groups that focused on the domains of health care delivery and management; workforce, training, and education; economics and finance; and information management. The commission has five key messages—a set of indicators and recommendations to improve access to safe, affordable surgical and anesthesia care in LMICs, and a template for a national surgical plan. Our five key messages are as follows:
- Approximately 5 billion people do not have access to safe, affordable surgical and anesthesia care when needed. Access is worst in LMICs, where nine of 10 people cannot access basic surgical care.
- An additional 143 million surgical procedures are needed in LMICs each year to save lives and prevent disability. Of the 313 million procedures undertaken worldwide each year, only 6 percent occur in the poorest countries, where more than a third of the world’s population lives. Low operative volumes are associated with high case-fatality rates from common, treatable surgical conditions. Unmet need is greatest in eastern, western, and central sub-Saharan Africa and south Asia.
- An estimated 33 million individuals face catastrophic health expenses to pay for surgical and anesthesia care each year. An additional 48 million cases of catastrophic expenditure are attributable to the nonmedical costs of accessing surgical care such as transportation, lodging, and food. A quarter of the people who have a surgical procedure will incur financial catastrophe as a result of seeking care. The burden of catastrophic expenditure for surgery is highest for LMICs and, within any country, lands most heavily on poor people.
- Investing in surgical services in LMICs is affordable, saves lives, and promotes economic growth. To meet present and projected population demands, urgent investment in human and physical resources for surgical and anesthesia care is needed. If LMICs were to scale up surgical services at rates achieved by the present best-performing LMICs, two-thirds of countries would be able to reach a minimum operative volume of 5,000 surgical procedures per 100,000 population by 2030. Without urgent and accelerated investment in surgical scale-up, LMICs will continue to have losses in economic productivity, estimated cumulatively at $12.3 trillion (2010 U.S. dollars, purchasing power parity) between 2015 and 2030.
- Surgery is an “indivisible, indispensable part of health care.”‡ Surgical and anesthesia care should be an integral component of a national health system in countries at all levels of development. Surgical services are a prerequisite for the full attainment of local and global health goals in areas as diverse as cancer, injury, cardiovascular disease, infection, and reproductive, maternal, neonatal, and child health. Universal health coverage and the health aspirations set out in the post-2015 sustainable development goals (SDGs) will be impossible to achieve without ensuring that surgical and anesthesia care is available, accessible, safe, timely, and affordable.
Meeting the challenges
In summary, the Commission’s key findings show that the human and economic consequences of untreated surgical conditions in LMICs are large and for many years have gone unrecognized. During the past two decades, global health has focused on individual diseases. The development of integrated health services and health systems has been somewhat neglected. As such, surgical care has been afforded low priority in the world’s poorest regions.
This report presents a clear challenge to this approach. As a new era of global health begins in 2015, the focus should be on the development of broad-based health systems solutions, and resources should be allocated accordingly. Surgical care has an incontrovertible, cross-cutting role in overcoming local and global health challenges. It is an important part of the solution to many diseases—for both old threats and new challenges—and a crucial component of a functional, responsive, and resilient health system. The health gains from scaling up surgical care in LMICs are great and the economic benefits substantial. They accrue across all disease-cause categories and at all stages of life, but especially benefit the world’s youth and young adult populations. The provision of safe and affordable surgical and anesthesia care when needed not only reduces premature death and disability, but also boosts welfare, economic productivity, capacity, and freedoms, contributing to long-term development. Our six core surgical indicators (see table) should be tracked and reported by all countries and global health organizations, such as the World Bank through the World Development Indicators, the World Health Organization through the Global Reference List of 100 Core Health Indicators, and entities tracking the SDGs.
At the opening meeting of The Lancet Commission on Global Surgery in January 2014, Jim Yong Kim, MD, PhD, President of the World Bank, stated “surgery is an indivisible, indispensable part of health care” and “can help millions of people lead healthier, more productive lives.”‡ In 2015, good reasons exist to ensure that access to surgical and anesthesia care is realized for all.
Core indicators for monitoring universal access to safe, affordable surgical and anesthesia care when needed
|Access to timely essential surgery||Percent of the population that can access, within 2 hours, a facility that can perform emergency cesarean section, laparotomy, and treatment of open fracture (the Bellwether Procedures)||A minimum of 80% coverage of essential surgical and anesthesia services per country by 2030|
|Specialist surgical workforce density||Number of specialist surgical, anesthetic, and obstetric physicians who are working, per 100,000 population||100% of countries with at least 20 surgical, anesthetic, and obstetric physicians per 100,000 population by 2030|
|Surgical volume||Procedures performed in an operating theater, per 100,000 population, per year||80% of countries by 2020 and 100% of countries by 2030 tracking surgical volume; a minimum of 5,000 procedures per 100,000 population by 2030|
|Perioperative mortality rate (POMR)||All-cause death rate prior to discharge among patients who have undergone a procedure in an operating theater, divided by the total number of procedures, presented as a percentage||80% of countries by 2020 and 100% of countries by 2030 tracking POMR; in 2020, evaluate global data and set national targets for 2030|
|Protection against impoverishing expenditure||Proportion of households protected against impoverishment from direct out-of-pocket (OOP) payments for surgical and anesthesia care||100% protection against impoverishment from OOP payments for surgical and anesthesia care by 2030|
|Protection against catastrophic expenditure||Proportion of households protected against catastrophic expenditure from direct OOP payments for surgical and anesthesia care||100% protection against catastrophic expenditure from OOP payments for surgical and anesthesia care by 2030|
Note: These indicators provide the most information when used and interpreted together; no single indicator provides an adequate representation of surgical and anesthesia care when analyzed independently.
LCoGS Global Surgery 2030 Report authors
*John G. Meara, MD, DMD, MBA, FACS, Boston, MA
*Andrew J. M. Leather, MB, BS, MS, FRCS, London, UK
*Lars Hagander, MD, PhD, MPH, Lund, Sweden
Blake C. Alkire, MD, Boston, MA
Nivaldo Alonso, MD, PhD, São Paulo, Brazil
Emmanuel A. Ameh, MB, BS, FACS, FWACS, Zaria, Nigeria
Stephen W. Bickler, MD, FACS, San Diego, CA
Lesong Conteh, MSc, PhD, London, UK
Anna J. Dare, MB, BCh, PhD, London, UK
Justine Davies, MD, London, UK
Eunice Dérivois Mérisier, MD, Port-au-Prince, Haiti
Shenaaz El-Halabi, MPH, Gaborone, Republic of Botswana
Paul E. Farmer, MD, PhD, Boston, MA
Atul Gawande, MD, MPH, FACS, Boston, MA
Rowan Gillies, MB, BS, FRACS, St. Leonards, NSW, Australia
Sarah L.M. Greenberg, MD, Boston, MA
Caris E. Grimes, BSc, MB, BS, MRCS, London, UK
Russell L. Gruen, MD, PhD, MPH, Melbourne, VIC, Australia
Edna Adan Ismail, SRN, CMB, SCM, Hargeisa, Somaliland
Thaim Buya Kamara, MB, BCh, FWACS, Freetown, Sierra Leone
Chris Lavy, OBE, MD, MCh, FCS, FRCS, Oxford, UK
Ganbold Lundeg, MD, PhD, Ulaanbaatar, Mongolia
Nyengo C. Mkandawire, MB, BS, MCh(Orth), FCS(ECSA), FRCS, Blantyre, Malawi
Nakul P. Raykar, MD, Boston, MA
Johanna N. Riesel, MD, Boston, MA
†Edgar Rodas, MD, FACS, Cuenca, Ecuador
John Rose, MD, San Diego, CA
Nobhojit Roy, MB, BS, MS, MPH, Deonar, India
Mark G. Shrime, MD, MPH, FACS, Boston, MA
Richard Sullivan, MD, PhD, London, UK
Stéphane Verguet, MS, MPP, PhD, Boston, MA
David Watters, MCh, FRACS, FRCSEd, Melbourne, VIC, Australia
Thomas G. Weiser, MD, Stanford, CA
Iain H. Wilson, MB, BCh, FRCA, Exeter, UK
Gavin Yamey, MB, BS, MPH, MA, MRCP, San Francisco, CA
Winnie Yip, PhD, Oxford, UK
*Joint first authors
†Prof. Rodas died March 2; the authors dedicate the report to him.
*Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015; published online April 27. Available at: http://dx.doi.org/10.1016/S0140-6736(15)60160-X. Accessed March 31, 2015.
†LMICs: Although this term has been used throughout the report for brevity, the commission acknowledges that tremendous income diversity exists between and within this group of countries.
‡Kim JY. Opening address to the inaugural “The Lancet Commission on Global Surgery” meeting. The World Bank. Jan 17, 2014. Boston, MA. Available at: www.globalsurgery.info/wp-content/uploads/2014/01/Jim-Kim-Global-Surgery-Transcribed.pdf. Accessed March, 31, 2015.