World Journal of Surgery

, Volume 39, Issue 8, pp 1867–1874 | Cite as

Strengthening Health Systems of Developing Countries: Inclusion of Surgery in Universal Health Coverage

  • Juliet S. OkorohEmail author
  • Victoria Chia
  • Emily A. Oliver
  • Marisa Dharmawardene
  • Robert Riviello
Original Scientific Report



Universal health coverage (UHC) has its roots in the Universal Declaration of Human Rights and has recently gained momentum. Out-of-pocket payments (OPP) remain a significant barrier to care. There is an increasing global prevalence of non-communicable diseases, many of which are surgically treatable. We sought to provide a comparative analysis of the inclusion of surgical care in operating plans for UHC in low- and middle-income countries (LMIC).


We systematically searched PubMed and Google Scholar using pre-defined criteria for articles published in English, Spanish, or French between January 1991 and November 2013. Keywords included “insurance,” “OPP,” “surgery,” “trauma,” “cancer,” and “congenital anomalies.” World Health Organization (WHO), World Bank, and Joint Learning Network for UHC websites were searched for supporting documents. Ministries of Health were contacted to provide further information on the inclusion of surgery.


We found 696 articles and selected 265 for full-text review based on our criteria. Some countries enumerated surgical conditions in detail (India, 947 conditions). Other countries mentioned surgery broadly. Obstetric care was most commonly covered (19 countries). Solid organ transplantation was least covered. Cancer care was mentioned broadly, often without specifying the therapeutic modality. No countries were identified where hospitals are required to provide emergency care regardless of insurance coverage. OPP varied greatly between countries. Eighty percent of countries had OPP of 60 % or more, making these services, even if partially covered, largely inaccessible.


While OPP, delivery, and utilization continue to represent challenges to health care access in many LMICs, the inclusion of surgery in many UHC policies sets an important precedent in addressing a growing global prevalence of surgically treatable conditions. Barriers to access, including inequalities in financial protection in the form of high OPP, remain a fundamental challenge to providing surgical care in LMICs.


Club Foot Obstetric Care Health Information Technology Universal Health Coverage National Health Insurance Scheme 
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.


Conflicts of interest

All authors declare no conflicts of interest.


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Copyright information

© Société Internationale de Chirurgie 2015

Authors and Affiliations

  • Juliet S. Okoroh
    • 1
    • 2
    Email author
  • Victoria Chia
    • 2
    • 3
  • Emily A. Oliver
    • 4
  • Marisa Dharmawardene
    • 5
  • Robert Riviello
    • 6
  1. 1.Department of SurgeryUniversity of California San FranciscoSan FranciscoUSA
  2. 2.University of California San Diego School of MedicineLa JollaUSA
  3. 3.Harvard T. H. Chan School of Public HealthBostonUSA
  4. 4.Department of Obstetrics and GynecologyThe Ohio State Wexner Medical CenterColumbusUSA
  5. 5.Department of OncologyUniversity of CalgaryCalgaryCanada
  6. 6.Center for Surgery and Public HealthBrigham and Women’s HospitalBostonUSA

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