Projections for Achieving the Lancet Commission Recommended Surgical Rate of 5000 Operations per 100,000 Population by Region-Specific Surgical Rate Estimates
We previously identified a range of 4344–5028 annual operations per 100,000 people 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 people. We evaluate rates of growth and estimate the time it will take to reach this minimum surgical rate threshold.
We aggregated country-level surgical rate estimates from 2004 to 2012 into the twenty-one Global Burden of Disease (GBD) regions. We calculated mean rates of surgery proportional to population size for each year and assessed the rate of growth over time. We then extrapolated the time it will take each region to reach a surgical rate of 5000 operations per 100,000 population based on linear rates of change.
All but two regions experienced growth in their surgical rates during the past 8 years. Fourteen regions did not meet the recommended threshold in 2012. If surgical capacity continues to grow at current rates, seven regions will not meet the threshold by 2035. Eastern Sub-Saharan Africa will not reach the recommended threshold until 2124.
The rates of growth in surgical service delivery are exceedingly variable. At current rates of surgical and population growth, 6.2 billion people (73 % of the world’s population) will be living in countries below the minimum recommended rate of surgical care in 2035. A strategy for strengthening surgical capacity is essential if these targets are to be met in a timely fashion as part of the integrated health system development.
Surgical care is recognized as a key component of a health system  and a growing body of evidence supports the need to scale up and improve surgical care. The Lancet Commission on Global Surgery (LCGS) has developed recommendations to reach these goals . Similarly, surgical services have become an important component of the Disease Control Priorities Project [3, 4]. In addition, a standardized set of metrics for surgical surveillance was proposed as part of the World Health Organization (WHO) Safe Surgery Saves Lives program in 2009 . Nevertheless, little progress has been made to facilitate acquisition of data regarding surgical intervention.
Global surgical volume estimates indicate a 34 % increase in surgical services from 234.2 million operations (95 % CI 187.2–282.2) in 2004 to 312.9 million operations (95 % CI 2.66.2–359.5) in 2012. In resource-poor settings, this growth was much more pronounced, from an estimated 8.1 million operations in 2004  to 19.6 million operations in 2012 (a 126 % growth rate) . Although this development is encouraging, considerable inequalities prevail; less than 7 % of operations are performed in poor-expenditure countries accounting for 37 % of the world’s population . The rate of growth is poorly understood and likely insufficient to meet public health needs in a timely way [6, 7, 8]. Although the possibility of a grand convergence in global health by 2035 has been proposed , the gap in access to surgical care is clearly far from being met.
In previous research, we identified a range of 4344–5028 operations per 100,000 population annually to be related to desirable health outcomes  including life expectancy of 74–75 years, a maternal mortality ratio of less than or equal to 100, and minimum surgical capacity to meet surgical disease prevalence. In addition, the LCGS recommends a minimum rate of 5000 operations per 100,000 population according to the specific country’s needs. We evaluate rates of growth and extrapolate the time it will take to reach the LCGS recommendation of 5000 operations per 100,000 population using current and prior estimates of country-level surgical rates.
We used country-level surgical rates from 2004  to 2012 . These were obtained from numerous data sources, and missing data were estimated using a multiple imputation strategy based on per capita health expenditure. This modeling strategy allowed us to provide 95 % confidence intervals for countries with missing data based on three hundred imputed datasets. From these reported surgical rates, corresponding ranges were calculated according to the population estimates for 2004 and 2012, respectively; a detailed description of these methods has been published elsewhere [6, 7]. Population and total health expenditure estimates were obtained from the World Bank Development Indicators .
We aggregated country-level surgical volume estimates into the twenty-one Global Burden of Disease (GBD) epidemiological regions. We then weighted country-level surgical volume estimates by population size for each country within their particular GBD regions,  allowing us to calculate mean rates of surgery for each GBD region for 2004 and 2012. We then calculated the linear rate of change over this 8-year time period. We extrapolated the time to reach a surgical rate of 5000 operations per 100,000 population based on each region’s observed rate of change.
Surgical rate per 100,000 operations per population, and percent rate increase by GBD region
Population in 2004
Surgical rate per 100,000 population in 2004
Population in 2012
Surgical rate per 100,000 population in 2012
Andean Latin America
Central Latin America
Central sub-Saharan Africa
Eastern sub-Saharan Africa
High-income Asia Pacific
High-income North America
North Africa and Middle East
Southern Latin America
Southern sub-Saharan Africa
Tropical Latin America
Western sub-saharan Africa
The rates of growth in surgical service delivery are exceedingly variable ranging from a 37 % decrease to a 364 % increase. Despite the overall increase in surgical services, many regions have not met the minimum recommended surgical rate, in this observational exercise. Although surgical rates of Eastern sub-Saharan Africa have increased 112 % in the last 8 years, it will still take this region 112 years at the current rate of growth to reach the recommended minimum threshold of 5000 operations per 100,000 population. While GBD regions that have not met the recommended threshold are often associated with higher rates of growth, some will take many years to reach the minimum threshold.
While rates of surgery are unlikely to change linearly, this exercise is useful to project how many years it may take regions to reach specific rates of surgery based on current rates of growth. As increased rates of surgery might have unexpected negative consequences if quality is poor, [8, 13] the quality of surgery in these settings requires further investigation. Additionally, considerable differences exist regarding access to surgical care within countries (i.e., rural and urban settings). It is highly likely that the majority of the surgical volume occurs in urban areas, while basic access to surgery in rural parts of countries remains unaddressed. Further research is needed to better understand and address differences within each country.
This observational exercise uses the estimated surgical rates from a modeling strategy that may be imprecise at the country level. The model is limited by the lack of widely available data, the case mix both in disease and surgical intervention, and reporting patterns of countries. We attempted to limit some of the reported variability in rates by aggregating data into 21 GBD regions, thus grouping countries with comparable characteristics and determining mean rates rather than relying on individual country-level rates. The decrease in surgical rates seen in Central Europe (37 %) and Southern Latin America (6 %) are likely due to several specific issues related to individual countries within the region. Central Europe’s country-level data show that one country (Hungary) reported a large surgical volume decrease, likely from miscategorization in the 2004 data. One country in the Southern Latin America region (Argentina) had a considerable decrease in total per capita health expenditure (adjusted to $US) resulting in a substantial decline in its imputed surgical rate. Another weakness is that this is purely an observational exercise based on surgical rate estimates from two points in time, and as such it fails to take into consideration other factors that could impact the delivery of surgical services and time to reach minimum threshold. We are also unable to determine why the rates of change vary across countries and regions.
Despite increasing evidence supporting surgical care as an important, cost-effective component of health systems strengthening, [9, 14] it has not been readily adopted by stake holders and donors. Our findings suggest that minimum rates of surgery are not currently being met for 5.5 billion people (79 %) of the world’s population. If this trend continues by 2035, there will be 6.2 billion people (73 % of the world’s population) living in countries that do not provide the minimum recommended rate of surgery. Ongoing monitoring and surveillance of these services will provide crucial information to better understand and address safety, quality, affordability, equity, and access to surgical services. Developing a reliable standardized surgical data collection system is an important first step to enable policy makers and stake holders to make informed, evidence-based decisions. A strategy for strengthening surgical capacity is essential if these targets are to be met as part of the integrated health system development.
Conflicts of interest
We declare that we have no conflicts of interest.
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