Remarkable gains have been made in global health in the past 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, life-saving 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 treatable conditions including appendicitis, hernia, fractures, obstructed labor, congenital anomalies, and breast and cervical cancer.
Although the term, low- and middle-income countries (LMICs), has been used throughout the report for brevity, the Commission realizes that tremendous income diversity exists between and within this group of countries.
In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, noncommunicable 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 a 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 the 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 was launched in January 2014. The commission brought together an international, multidisciplinary team of 25 commissioners, supported by advisers and collaborators in more than 110 countries and 6 continents.
We formed 4 working groups that focused on the domains of health care delivery and management; workforce, training, and education; economics and finance; and information management. Our commission has 5 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 5 key messages are presented as follows:
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5 billion people do not have access to safe, affordable surgical and anesthesia care when needed. Access is worst in low-income and lower-middle-income countries, where 9 of 10 people cannot access basic surgical care.
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143 million additional 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% 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.
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33 million individuals face catastrophic health expenditure because of the payment for surgery and anesthesia care each year. An additional 48 million cases of catastrophic expenditure are attributable to the nonmedical costs of accessing surgical care. 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 in low-income and lower-middle-income countries and, within any country, lands most heavily on poor people.
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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 5000 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 US $12.3 trillion (2010 US$, 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 will be impossible to achieve without ensuring that surgical and anesthesia care is available, accessible, safe, timely, and affordable.
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 2 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. Our 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 achievement of 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 our 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 6 core surgical indicators ( Table ) should be tracked and reported by all countries and global health organizations, such as the World Bank through the World Development Indicators, World Health Organization through the Global Reference List of 100 Core Health Indicators, and entities tracking the sustainable development goals.
