World Journal of Surgery

, Volume 40, Issue 11, pp 2611–2619 | Cite as

Bellwether Procedures for Monitoring and Planning Essential Surgical Care in Low- and Middle-Income Countries: Caesarean Delivery, Laparotomy, and Treatment of Open Fractures

  • Kathleen M. O’Neill
  • Sarah L. M. Greenberg
  • Meena Cherian
  • Rowan D. Gillies
  • Kimberly M. Daniels
  • Nobhojit Roy
  • Nakul P. Raykar
  • Johanna N. Riesel
  • David Spiegel
  • David A. Watters
  • Russell L. Gruen
Original Scientific Report



Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care.


We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures—which we term “bellwether procedures”—was associated with performing a full range of essential surgical procedures.


The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p < 0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures.


Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team.


Caesarean Delivery Open Fracture Clubfoot Surgical Care Universal Health Coverage 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Funding was provided by Boston Children’s Hospital. The authors acknowledge the Lancet Commission on Global Surgery. RLG was supported by a Practitioner Fellowship from the Australian National Health and Medical Research Council.

Author contribution

Because this project required international collaboration, many were involved with the conception and design of the study, analysis of the data, and production of the final manuscript. In particular, KMO, SLMG, MC, RDG, NR, NPR, JNR, DS, DW, and RLG were all intimately involved with the conception and design of the project. KMO, SLMG, MC, RDG, and NPR were critical for the acquisition of the data. KMD was critically important for the analysis and interpretation of the data. All authors contributed to editing of the final manuscript and gave final approval of this submission.


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Copyright information

© Société Internationale de Chirurgie 2016

Authors and Affiliations

  • Kathleen M. O’Neill
    • 1
    • 2
  • Sarah L. M. Greenberg
    • 1
    • 3
  • Meena Cherian
    • 4
  • Rowan D. Gillies
    • 5
  • Kimberly M. Daniels
    • 1
    • 6
  • Nobhojit Roy
    • 7
    • 8
  • Nakul P. Raykar
    • 1
    • 9
  • Johanna N. Riesel
    • 1
    • 10
  • David Spiegel
    • 11
  • David A. Watters
    • 12
    • 13
  • Russell L. Gruen
    • 14
    • 15
  1. 1.Program in Global Surgery and Social ChangeHarvard Medical SchoolBostonUSA
  2. 2.Department of SurgeryYale New Haven HospitalNew HavenUSA
  3. 3.Department of SurgeryMedical College of WisconsinMilwaukeeUSA
  4. 4.WHO Emergency and Essential Surgical Care ProgrammeThe World Health Organization, HeadquartersGenevaSwitzerland
  5. 5.Royal North Shore Hospital, Plastic, Reconstructive and BurnsSt LeonardsAustralia
  6. 6.Department of Plastic and Oral SurgeryBoston Children’s HospitalBostonUSA
  7. 7.Department of SurgeryBhabha Atomic Research Center (BARC) HospitalMumbaiIndia
  8. 8.Department of Public Health SciencesKarolinska InstitutetStockholmSweden
  9. 9.Beth Israel Deaconess Medical CenterBostonUSA
  10. 10.The Harvard Program in Plastic SurgeryBostonUSA
  11. 11.Department of OrthopedicsChildren’s Hospital of PhiladelphiaPhiladelphiaUSA
  12. 12.Royal Australasian College of SurgeonsEast MelbourneAustralia
  13. 13.School of Medicine, Faculty of Health, Barwon HealthDeakin UniversityGeelongAustralia
  14. 14.The Alfred Hospital and Monash UniversityMelbourneAustralia
  15. 15.Nanyang Technological UniversitySingaporeSingapore

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