Comment
Global access to surgical care: moving forward Global surgical care is gaining ground on the public health platform. Throughout 2015–16, the World Bank is publishing the long-anticipated third edition of its Disease Control Priorities (DCP3). First published in 1993,1 these reports aim to systematically identify effective interventions to address the disease burden in low-income and middle-income countries. For the first time since its inception, the DCP now includes a distinct volume on the value of surgical care. Volume 1— Essential Surgery2—focuses on the benefits of surgical care, including its potential to substantially decrease mortality while being exceptionally cost-effective; the issues of access to life-saving surgery, perioperative safety, and the inclusion of surgery in universal health coverage are also specifically addressed. The recognition of surgery as an essential component of global public health stems from a growing body of academic literature detailing the disparities in access to surgical care. Population-based surveys have been instrumental in quantifying the unmet need for surgical care, and hospital-based studies have shed light on deficiencies in human and material resources required for basic surgical care. Global estimates of surgical care and need, arising from complex statistical models, have also been essential in quantifying the problem and have been especially effective in gaining the attention of stakeholders and decision-makers from outside the surgical sphere. In 2008, Weiser and colleagues3 estimated that, of the 234 million surgical procedures done annually worldwide, only 3·5% occurred in countries with health expenditures of US$100 or less per capita. Funk and colleagues4 estimated that more than 2 billion people worldwide lack access to adequate surgical care. In The Lancet Global Health, Blake Alkire and colleagues5 now provide additional measures to help us gain political priority on the public health agendas. In this study, Alkire and colleagues modelled access to surgery in 180 countries on the basis of four criteria: timeliness, surgical capacity, safety, and affordability. Based on their probability models, 4·8 billion people, or 68% of the world’s population, lack access to adequate surgical care. This proportion varied greatly according to income classification, with 99·5% of the population in lowincome countries—as opposed to 13·9% in high-income countries—with inadequate access. www.thelancet.com/lancetgh Vol 3 June 2015
Besides providing further evidence that deficiencies in access to surgical care remain a major public health concern, this study’s methods and findings shed light on important steps forward in improving access to surgery worldwide. Complex statistical models that provide global estimates rely on primary data collection; in other words, estimates from models are only as reliable as their inputs. To move things forward, we must continue to quantify the problem at the grassroots level; measurements of the prevalence of surgical diseases, the availability of resources required for surgical care, and the outcomes of surgical procedures will remain essential components of future studies. However, now that increasing attention is being paid to surgery in public health, we must also capitalise on this opportunity to move beyond descriptive studies. Charles Mock recently issued a call for the academic global surgery community to take major steps forward in the literature.6 Now that a robust body of literature has detailed the need, the time has come to delineate root causes, design effective interventions, and measure processes and outcomes over time. The breakdown of access to surgical care into timeliness, capacity, safety, and affordability could be particularly useful in guiding these future studies. The climate is ripe for major advances in improving access to surgical care worldwide. Surgical trainees are increasingly interested in global health.7 The resolution entitled “Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage” has been unanimously adopted by the World Health Organization’s Executive Board.8 The Lancet Commission on Global Surgery has gained momentum and will hopefully provide a unified voice for the community.9 We must capitalise on these opportunities to finally provide the “neglected stepchild”10 with the attention it deserves.
See Articles page e316
*Evan G Wong, Dan L Deckelbaum, Tarek Razek Centre for Global Surgery, McGill University, Montreal, QC H3G 1A4, Canada [email protected] The Centre for Global Surgery is supported by the Grand Challenges Canada Grant (Fall 2014). We declare no competing interests. Copyright © Wong et al. Open Access article distributed under the terms of CC BY-NC-ND.
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Jamison DT, Mosley WH, Measham AR, Bobadilla JL, eds. Disease control priorities in developing countries. New York: Oxford University Press, 1993. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN. Disease control priorities, 3rd edn: vol 1. Essential surgery. Washington, DC: World Bank, 2015. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372: 139–44. Funk LM, Weiser TG, Berry WR, et al. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet 2010; 376: 1055–61. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Health 2015; 3: e316–23. Mock C. Surgical capacity surveys: a call for papers on the next steps for moving beyond descriptive data. World J Surg 2015; 39: 811–12.
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Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg 2009; 208: 304–12. GIEESC. Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. Geneva: World Health Organization, 2014. 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. http://dx.doi.org/10.1016/ S0140-6736(15)60160-X. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg 2008; 32: 533–36.
www.thelancet.com/lancetgh Vol 3 June 2015
Global access to surgical care: moving forward Global surgical care is gaining ground on the public health platform. Throughout 2015–16, the World Bank is publishing the long-anticipated third edition of its Disease Control Priorities (DCP3). First published in 1993,1 these reports aim to systematically identify effective interventions to address the disease burden in low-income and middle-income countries. For the first time since its inception, the DCP now includes a distinct volume on the value of surgical care. Volume 1— Essential Surgery2—focuses on the benefits of surgical care, including its potential to substantially decrease mortality while being exceptionally cost-effective; the issues of access to life-saving surgery, perioperative safety, and the inclusion of surgery in universal health coverage are also specifically addressed. The recognition of surgery as an essential component of global public health stems from a growing body of academic literature detailing the disparities in access to surgical care. Population-based surveys have been instrumental in quantifying the unmet need for surgical care, and hospital-based studies have shed light on deficiencies in human and material resources required for basic surgical care. Global estimates of surgical care and need, arising from complex statistical models, have also been essential in quantifying the problem and have been especially effective in gaining the attention of stakeholders and decision-makers from outside the surgical sphere. In 2008, Weiser and colleagues3 estimated that, of the 234 million surgical procedures done annually worldwide, only 3·5% occurred in countries with health expenditures of US$100 or less per capita. Funk and colleagues4 estimated that more than 2 billion people worldwide lack access to adequate surgical care. In The Lancet Global Health, Blake Alkire and colleagues5 now provide additional measures to help us gain political priority on the public health agendas. In this study, Alkire and colleagues modelled access to surgery in 180 countries on the basis of four criteria: timeliness, surgical capacity, safety, and affordability. Based on their probability models, 4·8 billion people, or 68% of the world’s population, lack access to adequate surgical care. This proportion varied greatly according to income classification, with 99·5% of the population in lowincome countries—as opposed to 13·9% in high-income countries—with inadequate access. www.thelancet.com/lancetgh Vol 3 June 2015
Besides providing further evidence that deficiencies in access to surgical care remain a major public health concern, this study’s methods and findings shed light on important steps forward in improving access to surgery worldwide. Complex statistical models that provide global estimates rely on primary data collection; in other words, estimates from models are only as reliable as their inputs. To move things forward, we must continue to quantify the problem at the grassroots level; measurements of the prevalence of surgical diseases, the availability of resources required for surgical care, and the outcomes of surgical procedures will remain essential components of future studies. However, now that increasing attention is being paid to surgery in public health, we must also capitalise on this opportunity to move beyond descriptive studies. Charles Mock recently issued a call for the academic global surgery community to take major steps forward in the literature.6 Now that a robust body of literature has detailed the need, the time has come to delineate root causes, design effective interventions, and measure processes and outcomes over time. The breakdown of access to surgical care into timeliness, capacity, safety, and affordability could be particularly useful in guiding these future studies. The climate is ripe for major advances in improving access to surgical care worldwide. Surgical trainees are increasingly interested in global health.7 The resolution entitled “Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage” has been unanimously adopted by the World Health Organization’s Executive Board.8 The Lancet Commission on Global Surgery has gained momentum and will hopefully provide a unified voice for the community.9 We must capitalise on these opportunities to finally provide the “neglected stepchild”10 with the attention it deserves.
See Articles page e316
*Evan G Wong, Dan L Deckelbaum, Tarek Razek Centre for Global Surgery, McGill University, Montreal, QC H3G 1A4, Canada [email protected] The Centre for Global Surgery is supported by the Grand Challenges Canada Grant (Fall 2014). We declare no competing interests. Copyright © Wong et al. Open Access article distributed under the terms of CC BY-NC-ND.
e298
Comment
1 2
3
4
5 6
e299
Jamison DT, Mosley WH, Measham AR, Bobadilla JL, eds. Disease control priorities in developing countries. New York: Oxford University Press, 1993. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN. Disease control priorities, 3rd edn: vol 1. Essential surgery. Washington, DC: World Bank, 2015. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372: 139–44. Funk LM, Weiser TG, Berry WR, et al. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet 2010; 376: 1055–61. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Health 2015; 3: e316–23. Mock C. Surgical capacity surveys: a call for papers on the next steps for moving beyond descriptive data. World J Surg 2015; 39: 811–12.
7
8
9
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Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg 2009; 208: 304–12. GIEESC. Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. Geneva: World Health Organization, 2014. 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. http://dx.doi.org/10.1016/ S0140-6736(15)60160-X. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg 2008; 32: 533–36.
www.thelancet.com/lancetgh Vol 3 June 2015
