World Journal of Surgery

, 33:1

Population Health Metrics for Surgery: Effective Coverage of Surgical Services in Low-Income and Middle-Income Countries

  • Doruk Ozgediz
  • Renee Hsia
  • Thomas Weiser
  • Richard Gosselin
  • David Spiegel
  • Stephen Bickler
  • Peter Dunbar
  • Kelly McQueen



Access to surgical services is emerging as a crucial issue in global public health. “Effective coverage” is a health metric used to evaluate essential health services in low- and middle-income countries. It measures the fraction of potential health gained that is actually realized for a given intervention by integrating the concepts of need, use, and quality.


This study applies the concept of effective coverage to surgical services by considering injuries and obstetric complications as high-priority surgical conditions in low- and middle-income countries.


Effective coverage for both is poor, but it is less well defined for traumatic conditions compared to obstetric conditions owing to a lack of data.


More primary and secondary data are critical to measure effective coverage and to estimate the resources required to improve access to surgical services in low- and middle-income countries.


  1. 1.
    Weiser TG, Regenbogen SE, Thompson KD et al (2008) An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372:139–144PubMedCrossRefGoogle Scholar
  2. 2.
    Debas H, Gosselin R, McCord C et al (2006) Surgery. In: Jamison D (ed) Disease Control Priorities in Developing Countries, 2nd edn. Oxford University Press, Oxford, UKGoogle Scholar
  3. 3.
    Shengelia B, Murray C, Adams OB (2003) Beyond access and utilization: defining and measuring health system coverage. In: Murray C, Evans D (eds) Health Systems Performance Assessment. World Health Organization, Geneva, pp 221–234Google Scholar
  4. 4.
    Murray CJ, Frenk J (2008) Health metrics and evaluation: strengthening the science. Lancet 371:1191–1199PubMedCrossRefGoogle Scholar
  5. 5.
    Ooms G, Van Damme W, Baker BK et al (2008) The ‘diagonal’ approach to Global Fund financing: a cure for the broader malaise of health systems? Global Health 4:6PubMedCrossRefGoogle Scholar
  6. 6.
    Reich MR, Takemi K, Roberts MJ et al (2008) Global action on health systems: a proposal for the Toyako G8 summit. Lancet 371:865–869PubMedCrossRefGoogle Scholar
  7. 7.
    Gosselin RA, Thind A, Bellardinelli A (2006) Cost/DALY averted in a small hospital in Sierra Leone: what is the relative contribution of different services? World J Surg 30:505–511PubMedCrossRefGoogle Scholar
  8. 8.
    Laxminarayan R, Mills AJ, Breman JG et al (2006) Advancement of global health: key messages from the Disease Control Priorities Project. Lancet 367:1193–1208PubMedCrossRefGoogle Scholar
  9. 9.
    McCord C, Chowdhury Q (2003) A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. Int J Gynaecol Obstet 81:83–92PubMedCrossRefGoogle Scholar
  10. 10.
    Gosselin R, Heitto M (2008) Cost-effectiveness of a district trauma hospital in Battambong, Cambodia. World J Surg 2008 Aug 21 [Epub ahead of print]Google Scholar
  11. 11.
    Lozano R, Soliz P, Gakidou E et al (2006) Benchmarking of performance of Mexican states with effective coverage. Lancet 368:1729–1741PubMedCrossRefGoogle Scholar
  12. 12.
    Shengelia B, Tandon A, Adams OB et al (2005) Access, utilization, quality, and effective coverage: an integrated conceptual framework and measurement strategy. Soc Sci Med 61:97–109PubMedCrossRefGoogle Scholar
  13. 13.
    Duda RB, Hill AG (2007) Surgery in developing countries: should surgery have a role in population-based health care? Bull Am Coll Surg 92:12–18, 35Google Scholar
  14. 14.
    Anonymous (2008) Current Procedural Terminology [cited June 25]. Available from:
  15. 15.
    Anonymous (2007) UNFPA Maternal Mortality Statistics [cited December 20]. Available from:
  16. 16.
    Mock CN, Jurkovich GJ, nii-Amon-Kotei D et al (1998) Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development. J Trauma 44:804–812 discussion 812–814PubMedCrossRefGoogle Scholar
  17. 17.
    Ronsmans C (2001) How can we monitor progress towards improved maternal health? In: Lerberge W, Kegels G, Brouwere V, (eds). Safe Motherhood Strategies: a Review of the Evidence. ITG Press, Antwerp, Belgium, 2001, pp 313–338Google Scholar
  18. 18.
    Ronsmans C, Graham WJ (2006) Maternal mortality: who, when, where, and why. Lancet 368:1189–1200PubMedCrossRefGoogle Scholar
  19. 19.
    Pearson L, Shoo R (2005) Availability and use of emergency obstetric services: Kenya, Rwanda, southern Sudan, and Uganda. Int J Gynaecol Obstet 88:208–215PubMedCrossRefGoogle Scholar
  20. 20.
    Baiden F, Amponsa-Achiano K, Oduro AR et al (2006) Unmet need for essential obstetric services in a rural district in northern Ghana: complications of unsafe abortions remain a major cause of mortality. Public Health 120:421–426PubMedCrossRefGoogle Scholar
  21. 21.
    Ronsmans C, Holtz S, Stanton C (2006) Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. Lancet 368:1516–1523PubMedCrossRefGoogle Scholar
  22. 22.
    Bailey P, Paxton A, Lobis S et al (2006) Measuring progress towards the MDG for maternal health: including a measure of the health system’s capacity to treat obstetric complications. Int J Gynaecol Obstet 93:292–299PubMedCrossRefGoogle Scholar
  23. 23.
    Hofman K, Primack A, Keusch G et al (2005) Addressing the growing burden of trauma and injury in low- and middle-income countries. Am J Public Health 95:13–17PubMedCrossRefGoogle Scholar
  24. 24.
    Kopits E, Cropper M (2005) Traffic fatalities and economic growth. Accid Anal Prev 37:169–178PubMedCrossRefGoogle Scholar
  25. 25.
    Krug EG, Sharma GK, Lozano R (2000) The global burden of injuries. Am J Public Health 90:523–526PubMedCrossRefGoogle Scholar
  26. 26.
    Mohan D (2004) Evidence-based interventions for road traffic injuries in South Asia. J Coll Physicians Surg Pak 14:746–747PubMedGoogle Scholar
  27. 27.
    Peden M, Scurdfield R, Sleet D et al (2004) World Report on Road Traffic Injury Prevention. World Health Organization, GenevaGoogle Scholar
  28. 28.
    Wang Z, Jiang J (2003) An overview of research advances in road traffic trauma in China. Traffic Inj Prev 4:9–16PubMedCrossRefGoogle Scholar
  29. 29.
    Joshipura M (2008) Trauma care in India: current scenario. World J Surg [Epub June 28]Google Scholar
  30. 30.
    Nantulya VM, Reich MR (2003) Equity dimensions of road traffic injuries in low- and middle-income countries. Inj Control Saf Promot 10:13–20PubMedCrossRefGoogle Scholar
  31. 31.
    Levine AC, Presser DZ, Rosborough S et al (2007) Understanding barriers to emergency care in low-income countries: view from the front line. Prehosp Disaster Med 22:467–470PubMedGoogle Scholar
  32. 32.
    Mock CN, Adzotor E, Denno D et al (1995) Admissions for injury at a rural hospital in Ghana: implications for prevention in the developing world. Am J Public Health 85:927–931PubMedCrossRefGoogle Scholar
  33. 33.
    Holmberg S, Nordberg E (1990) Surgical rates in Africa: variations and their possible explanations. Trop Geogr Med 42:352–358PubMedGoogle Scholar
  34. 34.
    Mock CN, Boland E, Acheampong F et al (2003) Long-term injury related disability in Ghana. Disabil Rehabil 25:732–741PubMedCrossRefGoogle Scholar
  35. 35.
    Gawande AA, Kwaan MR, Regenbogen SE et al (2007) An Apgar score for surgery. J Am Coll Surg 204:201–208PubMedCrossRefGoogle Scholar
  36. 36.
    Bickler SW, Telfer ML, Sanno-Duanda B (2003) Need for paediatric surgery care in an urban area of The Gambia. Trop Doct 33:91–94PubMedGoogle Scholar
  37. 37.
    Bickler S, Spiegel D (2008) Global surgery—defining a research agenda. Lancet [Epub June 25]Google Scholar
  38. 38.
    Anonymous (2007) Maternal Mortality in 2005: Estimates Developed by WHO, UNICEF, UNFPA, and The World Bank: WHO, UNICEF, UNFPA, and The World BankGoogle Scholar
  39. 39.
    Hill K, El Arifeen S, Koenig M et al (2006) How should we measure maternal mortality in the developing world? A comparison of household deaths and sibling history approaches. Bull WHO 84:173–180PubMedGoogle Scholar
  40. 40.
    Bickler SW, Sanno-Duanda B (2000) Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia. Bull WHO 78:1330–1336PubMedGoogle Scholar
  41. 41.
    Filippi V, Brugha R, Browne E et al (2004) Obstetric audit in resource-poor settings: lessons from a multi-country project auditing ‘near miss’ obstetrical emergencies. Health Policy Plan 19:57–66PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2008

Authors and Affiliations

  • Doruk Ozgediz
    • 1
  • Renee Hsia
    • 2
  • Thomas Weiser
    • 3
  • Richard Gosselin
    • 4
  • David Spiegel
    • 5
  • Stephen Bickler
    • 6
  • Peter Dunbar
    • 7
  • Kelly McQueen
    • 8
  1. 1.Division of Pediatric SurgeryTorontoCanada
  2. 2.University of California, San FranciscoSan FranciscoUSA
  3. 3.Department of Health Policy and ManagementHarvard UniversityBostonUSA
  4. 4.School of Public Health, University of California at BerkeleyBerkeleyUSA
  5. 5.University of Pennsylvania, Children’s Hospital of PhiladelphiaPhiladelphiaUSA
  6. 6.Division of Pediatric SurgeryUniversity of California at San DiegoSan DiegoUSA
  7. 7.Department of AnesthesiaUniversity of WashingtonSeattleUSA
  8. 8.Harvard Humanitarian InitiativeHarvard UniversityCambridgeUSA

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