World Journal of Surgery

, Volume 39, Issue 9, pp 2168–2172 | Cite as

Projections for Achieving the Lancet Commission Recommended Surgical Rate of 5000 Operations per 100,000 Population by Region-Specific Surgical Rate Estimates

  • Tarsicio Uribe-Leitz
  • Micaela M. Esquivel
  • George Molina
  • Stuart R. Lipsitz
  • Stéphane Verguet
  • John Rose
  • Stephen W. Bickler
  • Atul A. Gawande
  • Alex B. Haynes
  • Thomas G. Weiser
Original Scientific Report

Abstract

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Introduction

Surgical care is recognized as a key component of a health system [1] 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 [2]. 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 [5]. 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 [6] to 19.6 million operations in 2012 (a 126 % growth rate) [7]. 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 [7]. 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 [9], 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 [10] 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.

Methods

We used country-level surgical rates from 2004 [6] to 2012 [7]. 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 [11].

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, [12] 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.

Results

The rate of change in surgical delivery was highly variable, with many of the poorest GBD regions experiencing high rates of growth. Four regions had more than a two-fold increase in surgical rates during these years: 112 % in Eastern sub-Saharan Africa, 122 % in South Asia, 294 % in Tropical Latin America, and 364 % in Central sub-Saharan Africa. Four other regions had rates of increase of more than fifty percent: 61 % in Central Asia, 80 % in Andean Latin America, 86 % in Oceania, and 90 % in Western sub-Saharan Africa. The slowest rate of growth occurred in High-income Asia pacific region (4 %). Two regions experienced a decrease in their surgical rates including Central Europe (37 % decrease) and Southern Latin America (6 % decrease). Seven regions, comprising mostly high-income economies, reached or exceeded the minimum threshold surgical rate in 2012. Conversely, the other fourteen regions that had not yet met the surgical rate threshold comprised low, lower-middle, and some upper-middle countries (Table 1).
Table 1

Surgical rate per 100,000 operations per population, and percent rate increase by GBD region

GBD regions

Population in 2004

(thousands)

Surgical rate per 100,000 population in 2004

(range)a

Population in 2012

(thousands)

Surgical rate per 100,000 population in 2012

(range)a

Rate increase

(%)

Andean Latin America

50,379

2338 (2139–2538)

55,976

4204 (4028–4381)

80

Australasia

24,184

8299 (8298–8299)

27,157

10,145 (10,117–10,173)

22

Caribbean

35,297

2938 (4428–5004)

38,686

3631 (3341–3921)

24

Central Asia

76,570

18,367 (2819–3325)

84,907

2949 (2624–3275)

61

Central Europe

119,777

6386 (6052–6719)

114,643

4016 (3760–4273)

−37

Central Latin America

219,109

3367 (3238–3497)

242,422

4065 (3937–4192)

21

Central sub-Saharan Africa

83,414

284 (254–315)

97,757

1318 (1144–1492)

364

East Asia

1345,832

2619 (2380–2859)

1375,458

2881 (2876–2886)

10

Eastern Europe

210,711

4083 (3765–4402)

208,142

5409 (4701–6118)

32

Eastern sub-Saharan Africa

308,820

281 (268–294)

383,758

595 (540–649)

112

High-income Asia Pacific

180,601

10,831 (10,675–10,987)

183,291

11,253 (10,066–12,442)

4

High-income North America

330,481

20,503 (20,503–20,503)

348,628

27,144 (27,132–27,155)

32

North Africa and Middle East

410,996

3187 (3055–3601)

456,078

3536 (3175–3898)

11

Oceania

8046

1322 (9048–10,656)

9441

2455 (2141–2768)

86

South Asia

1462,286

352 (326–379)

1628,583

782 (691–873)

122

Southeast Asia

573,513

1670 (1543–1797)

625,871

2178 (1908–2448)

30

Southern Latin America

58,505

5921 (5532–6312)

61,947

5543 (4880–6207)

−6

Southern sub-Saharan Africa

67,065

4304 (3954–4653)

73,545

4967 (4277–5657)

15

Tropical Latin America

192,563

1543 (1534–1551)

205,343

6071 (5237–6906)

294

Western Europe

405,124

10,443 (10,385–10,502)

422,605

12,628 (12,540–12,717)

21

Western sub-saharan Africa

289,859

595 (581–609)

356,692

1131 (996–1266)

90

aRanges calculated from the 99 % prediction interval from 300 imputed datasets for each country based on total health expenditure per capita

The time to reach a surgical rate of 5000 operations per 100,000 people per GBD region based on linearly extrapolating their observed rates of growth is shown in Fig. 1. All but two regions experienced growth in their surgical rates during the past 8 years. Central Europe’s estimated number of surgical operations in 2004 was 6386 per 100,000 people and decreased to 4016 operations per 100,000 people in 2012. Southern Latin America’s estimated number of surgical operations in 2004 was 5921 per 100,000 people and decreased to 5543 operations per 100,000 people in 2012. Andean Latin America will reach minimum threshold by 2015. However, Central Latin America, Central Asia, Caribbean, and Oceania regions will take 11, 15, 16, and 18 years, respectively, to reach the minimum threshold. If surgical capacity continues to grow at current rates, seven regions will not meet the recommended surgical rate threshold by 2035. Central sub-Saharan Africa will reach the recommended threshold in 2041, North Africa and Middle East in 2046, Southeast Asia in 2056, Western sub-Saharan Africa in 2070, East Asia in 2077, and South Asia in 2091. Eastern sub-Saharan Africa will not reach the recommended threshold until 2124.
Fig. 1

Time to reach surgical rate threshold by GBD region

Discussion

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.

Notes

Conflicts of interest

We declare that we have no conflicts of interest.

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Copyright information

© Société Internationale de Chirurgie 2015

Authors and Affiliations

  • Tarsicio Uribe-Leitz
    • 1
  • Micaela M. Esquivel
    • 1
  • George Molina
    • 2
    • 3
  • Stuart R. Lipsitz
    • 2
  • Stéphane Verguet
    • 4
  • John Rose
    • 5
    • 6
  • Stephen W. Bickler
    • 6
  • Atul A. Gawande
    • 2
  • Alex B. Haynes
    • 2
    • 3
  • Thomas G. Weiser
    • 1
  1. 1.Department of SurgeryStanford University, School of MedicineStanfordUSA
  2. 2.Ariadne Labs, Brigham and Women’s Hospital and Harvard TH Chan School of Public HealthBostonUSA
  3. 3.Department of SurgeryMassachusetts General HospitalBostonUSA
  4. 4.Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonUSA
  5. 5.Center for Surgery and Public Health, Brigham and Women’s HospitalBostonUSA
  6. 6.Division of Pediatric Surgery, Rady Children’s HospitalUniversity of California San DiegoSan DiegoUSA

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