The Lancet: Two-thirds of the world's population have no access to safe and affordable surgery

April 26, 2015

Millions of people are dying from common, easily treatable conditions like appendicitis, fractures, or obstructed labour because they do not have access to, or can't afford, proper surgical care, according to a major new Commission, published in The Lancet.

The Commission reveals that five billion people worldwide do not have access to safe and affordable surgery and anaesthesia when they need it, and access is worst in low-income and lower-middle income countries, where as many as nine out of ten people cannot access basic surgical care.

Just under a third of all deaths in 2010 (32·9%, 16·9 million deaths) were from conditions treatable with surgery - well surpassing the number of deaths from HIV / AIDS, TB, and malaria combined. Yet, despite this enormous burden of death and illness -which is largely borne by the world's poorest people - surgery has, until now, been overlooked as a critical need for the health of the world's population. As a result, untreated surgical conditions have exerted substantial but largely unrecognized negative effects on human health, welfare, and economic development.

According to Lars Hagander, one of the Commission's lead authors, from Lund University, Sweden, "Too many people are dying from common, treatable surgical conditions, such as appendicitis, obstructed labour, and fractures. The problem is especially acute in the low- and middle-income countries of eastern, western and central sub-Saharan Africa, and South and Southeast Asia."*

"In the absence of surgical care, common, easily treatable illnesses become fatal," says Andy Leather, Director of the King's Centre for Global Health, King's College London, UK, and another of the Commission's lead authors. "The global community cannot continue to ignore this problem - millions of people are already dying unnecessarily, and the need for equitable and affordable access to surgical services is projected to increase in the coming decades, as many of the worst affected countries face rising rates of cancer, cardiovascular disease, and road accidents."*

Of the 313 million operations done worldwide each year, just one in 20 occur in the poorest countries, where over a third of the world's population lives. New estimates produced for the Commission find that there is a global shortfall of at least 143 million surgical procedures every year, with some regions needing nearly twice as many additional operations as others.

The Commission also finds that a quarter of people worldwide who have a surgical procedure will incur financial catastrophe - costs that they can't afford and which drive them into poverty - as a result of seeking care. The burden of catastrophic expenditure on surgery is highest in low-income and lower-middle-income countries and, within any country, lands most heavily on poor people.

Despite the overwhelming magnitude of the problem, the Commission estimates that the countries where access to surgery is weakest could be scaled up to acceptable, and achievable, levels of access to surgery by 2030 with an investment of $US 420 billion, a cost far outweighed by the devastating economic cost to countries, communities, and families incurred by the current global shortfall in access to surgery. This highly cost-effective investment in surgery needs to be accompanied by sustainable financing mechanisms across the health care system, say the authors, and a firm commitment to universal health coverage.

The Commission was written by a group of 25 leading experts from across the fields of surgery and anaesthesia, with contributions from more than 110 countries. The report examines the case for surgery as an integral component of health care, focusing on low- and middle-income countries, where need is greatest.

In addition to providing detailed figures on the economic returns that might be expected to accompany the needed global expansion of surgery, the Commission also provides a much-needed set of indicators and recommendations to improve access to safe and affordable surgery and anaesthesia, and a policy template for national surgical plans. It is accompanied by a substantial body of original research which was used to inform the Commission's findings, and is published in the journals Surgery and The Lancet Global Health.

"Although the scale-up costs are large, the costs of inaction are higher, and will accumulate progressively with delay," says Commission lead author John Meara, Kletjian Professor in Global Surgery at Harvard Medical School, and Associate Professor of Surgery at Boston Children's Hospital, USA. "There is a pervasive misconception that the costs of providing safe and accessible surgery put it beyond the reach of any but the richest countries. But our work for this Commission clearly shows that not only are the costs of providing these essential services lower than might have been thought, but that scale-up of surgical and anaesthesia care should be viewed as a highly-cost-effective investment, rather than a cost."*

"Surgical conditions--whether cancers, injuries, congenital anomalies, childbirth complications, or infectious disease manifestations--are ubiquitous, growing, and marginalising to those who are afflicted by them. The good news is that we believe it is possible to turn this dire situation around within the next two decades - but only if the international community wakes up to the enormous scale of the problem, and commits to the provision of better global surgical and anaesthesia care wherever it is needed."*

The Commission will be launched on Monday 27 April with a day-long symposium at the Royal Society of Medicine in London, UK, followed by a day long conference Global surgery, anaesthesia, and obstetrics: shifting paradigms and challenging generations organised by the Royal Society of Medicine and Royal College of Surgeons of England.

* Quotes direct from authors and cannot be found in text of Commission.

The Lancet

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