Summary Background Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well ...quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures—caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair—to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety. Methods We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates. Findings From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8–19·9), 2·2 per 1000 operations for appendectomy (0·0–17·2), and 4·9 per 1000 operations for groin hernia (0·0–11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs. Interpretation All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care. Funding None.
In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast ...and cervical cancer. The provision of safe and affordable surgical and anaesthesia care when needed not only reduces premature death and disability, but also boosts welfare, economic productivity, capacity, and freedoms, contributing to long-term development.
Summary The World Bank will publish the nine volumes of Disease Control Priorities , 3rd edition, in 2015–16. Volume 1— Essential Surgery —identifies 44 surgical procedures as essential on the basis ...that they address substantial needs, are cost effective, and are feasible to implement. This report summarises and critically assesses the volume's five key findings. First, provision of essential surgical procedures would avert about 1·5 million deaths a year, or 6–7% of all avertable deaths in low-income and middle-income countries. Second, essential surgical procedures rank among the most cost effective of all health interventions. The surgical platform of the first-level hospital delivers 28 of the 44 essential procedures, making investment in this platform also highly cost effective. Third, measures to expand access to surgery, such as task sharing, have been shown to be safe and effective while countries make long-term investments in building surgical and anaesthesia workforces. Because emergency procedures constitute 23 of the 28 procedures provided at first-level hospitals, expansion of access requires that such facilities be widely geographically diffused. Fourth, substantial disparities remain in the safety of surgical care, driven by high perioperative mortality rates including anaesthesia-related deaths in low-income and middle-income countries. Feasible measures, such as WHO's Surgical Safety Checklist, have led to improvements in safety and quality. Fifth, the large burden of surgical disorders, cost-effectiveness of essential surgery, and strong public demand for surgical services suggest that universal coverage of essential surgery should be financed early on the path to universal health coverage. We point to estimates that full coverage of the component of universal coverage of essential surgery applicable to first-level hospitals would require just over US$3 billion annually of additional spending and yield a benefit–cost ratio of more than 10:1. It would efficiently and equitably provide health benefits, financial protection, and contributions to stronger health systems.
Abstract Background It was previously estimated that 234·2 million operations were performed worldwide in 2004. The association between surgical rates and population health outcomes is not clear. We ...re-estimated global surgical volume to track changes over time and assess rates associated with healthy populations. Methods We gathered demographic, health, and economic data for 194 WHO member states. Surgical volumes were obtained from published studies and other reports from 2005 onwards. We estimated rates of surgery for all countries without available data based on health expenditure in 2012 and assessed the proportion of surgery comprised by caesarean delivery. The rate of surgery was plotted against life expectancy to describe the association between surgical care and this health indicator. Findings We identified 66 countries reporting surgical data between 2005 and 2013. We estimate that 312·9 million operations (95% CI 266·2–359·5) took place in 2012—a 33·6% increase over 8 years; the largest proportional increase occurred in countries spending US$400 or less per capita on health care. Caesarean delivery comprised 29·8% (5·8 million operations) of the total surgical volume in poor health expenditure countries compared with 10·8% (7·8 million operations) in low health expenditure countries and 2·7% (5·1 million operations) in high health expenditure countries. We noted a correlation between increased life expectancy and increased surgical rates up to 1533 operations per 100 000 people, with significant but less dramatic improvement above this rate. Interpretation Surgical volume is large and continues to grow in all economic environments. A single procedure—caesarean delivery—comprised almost a third of surgical volume in the most resource-limited settings. Surgical care is an essential part of health care and is associated with increased life expectancy, yet many low-income countries fail to achieve basic levels of service. Improvements in capacity and delivery of surgical services must be a major component of health system strengthening. Funding None.
Abstract Background The global volume of surgery in 2012 is estimated at 312·9 million operations per year, but rates of surgery vary substantially. Maternal health advocates proposed minimum ...caesarean delivery rates for benchmarking and to improve perinatal outcomes; however, this has not been done for surgery because the association between rates of surgical care provision as a whole and population health outcomes have not been well described. We use available data to estimate minimum rates of surgery that are associated with important health indicators. Methods We defined surgical operations as procedures done in operating theatres that need general or regional anaesthesia or profound sedation to control pain. We used four strategies to identify rates of surgery based on estimated rates of surgery per country for 2012 associated with life expectancy of 74–75 years; estimated rates of surgery associated with a maternal mortality ratio of less than or equal to 100 per 100 000 live births; estimated minimum need for surgery in the 21 Global Burden of Disease (GBD) regions based on the prevalence of disorders; and surgical rates from the so-called 4C countries (Chile, China, Costa Rica, and Cuba) identified in The Lancet Commission on Global Surgery as exemplary for their achievement of high health status, despite resource limitations. Findings Based on 2012 national surgical rates, countries with reported life expectancy of 74–75 years (n=17) had a median surgical rate of 4392 (IQR 2897–4873) operations per 100 000 population annually. The median surgical rate associated with maternal mortality ratio lower than 100 (n=109) is 5028 (IQR 4139–6778) operations per 100 000 population annually. The median surgical rate estimated for all 21 GBD regions was 4669 (IQR 4339–5291) operations per 100 000 population annually. The 4C countries had a mean surgical rate of 4344 (95% CI 2620–6068) operations per 100 000 population annually. 13 of the 21 GBD regions, accounting for 78% of the world's population, do not achieve the lowest end of the surgical rate range. Interpretation We identified a surprisingly narrow range of surgical rates associated with important health indicators. This target range can be used for benchmarking of surgical services, and as part of a policy aimed at strengthening health-care systems and surgical capacity. Funding None.
Abstract Background Recent work has indicated an increase in surgical services, especially in resource poor settings. However, the rate of growth is poorly understood and likely insufficient to meet ...public health needs. We previously identified a range of 4344 to 5028 operations per 100 000 population annually to be related to desirable health outcomes. From this and other evidence, the Lancet Commission on Global Surgery recommends a minimum rate of 5000 operations per 100 000 population. We evaluate rates of growth in surgery and estimate the time it will take to reach this minimum surgical rate threshold. Methods We aggregated 2004 and 2012 country-level surgical rate estimates into the 21 Global Burden of Disease (GBD) regions. We calculated mean rates of surgery proportional to population size and estimate rate of growth between these years. We then extrapolated the time it will take to reach a surgical rate of 5000 operations per 100 000 population based on linear rates of change. Findings All but two regions (central Europe and southern Latin America) experienced growth in their surgical rates during the past 8 years; the fastest growth occurred in regions with the lowest surgical rates. 14 regions representing 79% of the world's population (5·5 billion people) did not meet the recommended surgical rate threshold in 2012. If surgical capacity grows at current rates, seven regions (central sub-Saharan Africa, east Asia, eastern sub-Saharan Africa, north Africa and middle east, south Asia, southeast Asia, and western sub-Saharan Africa) will not meet the recommended surgical rate threshold by 2035; Eastern Sub-Saharan Africa will not reach this level until 2124. Interpretation The rates of growth in surgical service delivery are exceedingly variable, but the largest growth rates were noted in the poorest regions. Although this study does not address the quality of care, and rates of surgery are unlikely to change linearly, this exercise is useful to project how many years it could take regions to reach specific surgical rates. At current rates of growth, 4·9 billion people (70% of the world's population) will still be living in countries below the minimum recommended rate of surgery in 2035. A strategy for strengthening surgical capacity is essential if these targets are to be met as part of integrated health system development. Funding None.
Abstract Background While surgical interventions occur at lower rates in resource-poor settings, rates of complication and death after surgery are substantial but have not been well quantified. A ...deeper understanding of outcomes is a crucial step to ensure that quality accompanies increased global access to surgical care. We aimed to assess mortality following surgery to assess the risks of such interventions in these environments. Methods We collected the most recent demographic, health, and economic data from WHO for 114 countries classified as low-income or lower-middle-income according to the World Bank in 2005. We searched OVID, MedLine, PubMed, and SCOPUS to identify studies in these countries reporting all-cause mortality after three commonly performed operations: caesarean delivery, appendectomy, and groin hernia repair. Reports from governmental and other agencies were also identified. We modelled surgical mortality rates for countries without reported data with the lasso technique that performs continuous variable subset selection to avoid model overfitting. We validated our model against known case fatality rates for caesarean delivery. We aggregated mortality results by subregion to account for variability in data availability. We then created collective surgical case fatality rates by WHO region. Findings We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality rates were 7·7 per 1000 operations for caesarean delivery (IQR 3–14), 4·0 per 1000 operations for appendectomy (IQR 0–17), and 4·7 per 1000 operations for hernia groin (IQR 0–13); all recorded deaths occurred during the same admission to hospital as the operation. Based on our model, case fatality rate estimates by subregion ranged from 0·7 (central Europe) to 13·9 (central sub-Saharan Africa) per 1000 caesarean deliveries, 5·6 (central Asia) to 6·4 (central sub-Saharan Africa) per 1000 appendectomies, and 3·5 (tropical Latin America) to 33·9 (central sub-Saharan Africa) per 1000 hernia repairs. Interpretation All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments, and substantially higher than those in middle-income and high-income settings. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care. Funding None.
Summary Background Surgery is an essential part of health care, but resources to ensure the availability of surgical services are often inadequate. We estimated the global distribution of operating ...theatres and quantified the availability of pulse oximetry, which is an essential monitoring device during surgery and a potential measure of operating theatre resources. Methods We calculated ratios of the number of operating theatres to hospital beds in seven geographical regions worldwide on the basis of profiles from 769 hospitals in 92 countries that participated in WHO's safe surgery saves lives initiative. We used hospital bed figures from 190 WHO member states to estimate the number of operating theatres per 100 000 people in 21 subregions throughout the world. To estimate availability of pulse oximetry, we sent surveys to anaesthesia providers in 72 countries selected to ensure a geographically and demographically diverse sample. A predictive regression model was used to estimate the pulse oximetry need for countries that did not provide data. Findings The estimated number of operating theatres ranged from 1·0 (95% CI 0·9–1·2) per 100 000 people in west sub-Saharan Africa to 25·1 (20·9–30·1) per 100 000 in eastern Europe. High-income subregions all averaged more than 14 per 100 000 people, whereas all low-income subregions, representing 2·2 billion people, had fewer than two theatres per 100 000. Pulse oximetry data from 54 countries suggested that around 77 700 (63 195–95 533) theatres worldwide (19·2% 15·2–23·9) were not equipped with pulse oximeters. Interpretation Improvements in public-health strategies and monitoring are needed to reduce disparities for more than 2 billion people without adequate access to surgical care. Funding WHO.
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