In the Sustainable Development Goals era, there is a new awareness of the need for an integrated approach to healthcare interventions and a strong commitment to Universal Health Coverage. To achieve the goal of strengthening entire health systems, surgery, as a crosscutting treatment modality, is indispensable. For any health system strengthening exercise, baseline data and longitudinal monitoring of progress are necessary. With improved data capabilities, there are unparalleled possibilities to map out and understand systems, integrating data from many sources and sectors. Nevertheless, there is also a need to prioritize among indicators to avoid information overload and data collection fatigue. There is a similar need to define indicators and collection methodology to create standardized and comparable data. Finally, there is a need to establish data pathways to ensure clear responsibilities amongst national and international institutions and integrate surgical metrics into existing mechanisms for sustainable data collection. This is a call to collect, aggregate, and analyze global anesthesia and surgery data, with an account of existing data sources and a proposed way forward.
À l’époque des objectifs du développement durable, on constate une nouvelle sensibilisation au besoin d’une approche intégrée dans les interventions en soins de santé et un fort engagement en faveur d’une couverture médicale universelle. Pour atteindre l’objectif du renforcement de systèmes entiers de santé, la chirurgie en tant que modalité thérapeutique transversale est indispensable. Pour toute activité de renforcement du système de santé, des données de référence et un suivi longitudinal des progrès sont nécessaires. Avec de meilleures données, il existe des possibilités sans équivalent de cartographier et de comprendre les systèmes, en intégrant des données provenant de multiples sources et secteurs. Néanmoins, il est également nécessaire de prioriser les indicateurs pour éviter une surcharge d’informations et une fatigue dans la collecte des données. Il existe un besoin similaire de définition des indicateurs et de la méthodologie de collecte afin de créer des données standardisées et comparables. Enfin, il est nécessaire d’établir des cheminements de données pour garantir des responsabilités claires entre les institutions nationales et internationales et intégrer les paramètres chirurgicaux dans les mécanismes existants pour une collecte durable des données. Ceci est un appel à la collecte, au regroupement et à l’analyse de données globales en anesthésie et en chirurgie avec un compte rendu des sources de données existantes et une proposition d’avancée.
There is increasing acknowledgement of the linkage between universal access to surgical, obstetric, anesthesia, and trauma care and global sustainable development. The international 2030 sustainable development agenda with its aspiration to Universal Health Coverage (UHC), and the 2015 World Health Assembly (WHA) Resolution 68.151 together with Decision WHA702 recognize the importance of UHC for surgical care and anesthesia. As such, there has never been a more opportune time for members of the international community to support the integration of surgical and anesthesia care into the global health agenda.
In the report Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development,2 it is estimated that five billion people do not have access to safe, affordable surgical and anesthesia care when needed and that one third of the global burden of disease requires surgical care or anesthesia-pain management, or both. Surgical disease encompasses any illness where outcomes can be improved through surgical care.3,4 Access is most limited in low- and middle-income countries (LMICs) where nine out of ten people cannot access basic surgical care. Untreated, many surgical conditions are a source of lifetime disability and can cause premature mortality.5 Surgical conditions claim an estimated 16.9 million lives per year.3
In 2012, it was estimated that 143 million additional surgical procedures are needed in LMICs every year to prevent disability and economic loss and to save lives. Of the 313 million procedures undertaken each year worldwide, only 6% occur in the poorest countries where over one third of the world’s population lives.6 Low operative case volumes are associated with higher complication rates and higher case-fatality rates from common, treatable surgical conditions. The unmet need is greatest in eastern, western, and central sub-Saharan Africa and south Asia.2
In 2015, the World Bank launched the first volume of its Disease Control Priorities 3rd Edition, dedicated to “essential surgery”, where 44 surgical procedures were identified as essential for population health.7 The range of diseases requiring surgical capacity is wide and includes the growing burden of non-communicable diseases such as diabetes, cardiovascular disease, and cancer as well as injuries sustained from road traffic accidents, natural disasters, humanitarian crises, and conflicts. Further, it is estimated that 33 million individuals face catastrophic health expenditure, defined as an expense > 10% of a household’s yearly expenditure, due to out-of-pocket payments for surgery and anesthesia care each year.8 An additional 48 million cases of catastrophic expenditure are attributable to the non-medical costs of accessing surgical care such as transportation.8 Globally, a quarter of people who have a surgical procedure incur financial catastrophe as a result of seeking care. Investing in surgical services in LMICs is affordable, saves lives, and promotes economic growth. The cost to scale up surgical systems to meet the minimum requirements in LMICs as suggested by the LCoGS is estimated at US$ 350 billion.9 This is a small investment compared with the estimated US$ 12.3 trillion loss of production in these countries if this is not undertaken.10 It is also important to see that the major shifts in global population dynamics through population age structure, particularly aging, very rapid urban population growth, high mortality due to non-intentional injury and violence, and increased migration will increase the need for working surgical systems in the future. Demographic and epidemiologic transitions are reshaping the requirements for investments in health.
The demographic structure, pace of growth, and relative size of a population impact the current and future demand for surgical care. The world population continues to grow, although at a slower pace than in recent decades. Between 2015 and 2050, an estimated 2.4 billion people are projected to enter the world population. Africa is the region with the highest rate of population growth, currently growing at 2.55% annually.11 The implications of population growth are particularly relevant as more than half of global population growth until 2040 is projected to occur in Africa. These structural changes are reshaping the requirements for investing in health and changing related policy measures. Population growth accentuates the current deficit in access to surgical care. Significant actions to strengthen health systems are warranted to achieve universal access to surgical and anesthesia care.
Surgery and anesthesia are an “indivisible, indispensable part of health care”.12 Indeed, surgical and anesthesia services are inherent to (and span across) diverse disciplines, such as oncology, injury, cardiovascular disease, infections, pain management, and reproductive, maternal, neonatal, and child healthcare. Surgical and anesthesia care is a prerequisite for all people to live to their fullest potential and for the attainment of local and global health targets.
Universal Health Coverage and the health aspirations set out in the 2030 agenda and its 17 sustainable development goals (SDGs) will be impossible to achieve without ensuring that safe, timely, and affordable surgical, obstetric, and anesthesia care is available and accessible. Within the changing global health landscape, surgical, obstetric, and anesthesia care should therefore form an integral component of national health systems in all countries, and the commitment to do so has already been made through the unanimous passing of the World Health Organization (WHO) resolution WHA 68.15. Baseline data and longitudinal monitoring of progress are a necessary component of health system strengthening. This can be achieved by creating standardized and comparable data sources. Surgical and anesthesia services require an adequate needs assessment such that policymakers can better understand present and projected demands. Indeed, baseline measurement is the first step toward understanding benchmarks.
This article will guide the reader through different data sources and potential improvements in data collection mechanisms to report on and monitor progress toward access to surgery and anesthesia care (Fig. 1).
Measurement in global surgery
While a wealth of global health data has been accrued, there is still a major gap in knowledge with respect to surgical inequities. This poses a challenge for policymakers in attempting to improve such services—i.e., they cannot change what is unmeasured. Therefore, at the global level, improvements in data collection are necessary to monitor progress towards UHC and the health-related SDGs. High-quality, timely, and reliable surgery and anesthesia data that are available, accessible, and can be applied (especially in resource poor areas) need significant coordination. Recognizing the paucity of global data collection in this area and the process to improve it, the 2015 WHO resolution WHA68.15 urged Member States to collect and compile data on the number, type, and indications of surgical procedures, referrals, and perioperative mortality in their respective countries and to share such data as appropriate.1 In 2017, the WHO Decision Point WHA70.22 further requested that the WHO Director-General biennially report to the World Health Assembly on the progress towards strengthening of emergency and essential surgical care and anesthesia as outlined in resolution 68.15 as part of the WHO and its Member States’ work under UHC and the 2030 agenda for sustainable development.13
Current global anesthesia and surgery metrics
Global surgery and anesthesia statistics depend on definitions of statistical units and populations for comparison and linkage. Surgical target goals are based on ensuring that a certain percentage of the population has access to specific services or resources or achieves a certain level of social, economic, or physical health. These measurements require a solid and regularly updated understanding of not only the number of people that live in a specific geo-location or country, but also other demographic descriptors (Fig. 2).14 Variables and classification systems are crucial to properly define, and then uniformly apply, consensus definitions in all nations. Various data sources and processes that are necessary, however, should at a minimum include population and housing censuses, a sample community, hospital surveys, and health information systems. To comprehensively, but not resource intensively, assess a surgical care system with a limited set of measures, the LCoGS identified as a priority the collection of a standardized set of six core surgical indicator data.2 These six indicators assess the preparedness, delivery, and impact of surgical care and are outlined in Table 1.
The indicators were reflected in the WHO 100 core health indicators15 (Table 2) and subsequently also accepted for inclusion in the World Bank’s world development indicators data set,16 where data are currently available for four of the indicators (Table 3).
In the most recent SDG atlas by the World Bank,17 the surgical workforce indicator is featured with a graphic visualization. While even some high-income countries are lacking enough health workers to meet the demand of the local population, low-income countries have ten times fewer physicians than high-income countries do.18 Shortages are severe in terms of surgical, anesthesia, and obstetric (SAO) care.
Evaluation of the present situation and need for action
Following the publication of the LCoGS report in July 2015, Commission members at the Program for Global Surgery and Social Change based at Harvard Medical School began to collect nationally representative data for each indicator in the 215 countries and independent economies recognized by the World Bank.19 This was the first attempt to systematically and comprehensively gather primary data on surgical systems to improve previously fragmented estimates. In 2017, a second round of data collection was carried out under the leadership of the International Student Surgical Network and King’s College London.20 Anesthesia-related data in Africa, Central America, and India are currently being collected by the World Federation of Societies of Anaesthesiologists (WFSA) and University of California San Francisco Anesthesia Global Health in Africa, Central America, and India.
The first report of the LCoGS on the six surgical indicators was created with data received from 64 countries in November 2015.21 The volume of data was sufficient for primary data for indicator 2 and modeled data for indicators 3, 5, and 6 to be included in the 2016 World Bank Development Indicators. A mixed methods approach to collecting these data included data retrieval through 1) direct contact with official bodies, 2) systematic reviews of published literature, and 3) internet searches of the grey literature.22 The second round of data collection has yielded similar amounts of data (manuscript in preparation). Hence, the number of countries providing data for at least one time point in the last years along the six indicators varies significantly.
These two rounds of data collection have been driven by academic institutions in high-income countries and we argue that this is an unsustainable model going forward. National data collection processes need to be owned and driven at the local level by the respective National Statistical Offices and Ministries of Health as they are the key stakeholders in the collection and utilization of health statistics. National realities and priorities must guide data collection to achieve national ownership and sustainability. Additionally, data collection across multiple countries must be harmonized and standardized to ensure comparability of data and benchmarking of achievements. The structure would ideally be that Ministries of Health report data to WHO that then sends this on to be freely and transparently available at the World Development Indicators platform of the World Bank. Another data dissemination platform is the WHO Global Health Observatory.
Data sources for surgical statistics
Despite surgical and anesthesia data still being limited in availability, the WHO service availability and readiness assessments (SARA) and the WHO-SAT administered by the WHO global initiative on emergency and essential surgical care have collected substantial data at the facility level. Other organizations have also contributed to the systematic collection of data relating to surgical care.23,24,25,26 Effective sampling methods represent an option to lessen the statistical burden placed on the national statistical system while capturing representative data at the subnational level.27
A current research collaboration between the German Global Surgery Association and WorldPop/Flowminder Foundation is exploring possible data capture techniques to accurately represent national data, respecting national statistical laws, while considering national budget and human resource constraints. From previous data collection initiatives, it has become apparent that certain components are needed for standardized and sustainable high-quality data collection (Table 4).
Data from different sources are used for multiple purposes at different levels of the healthcare system: health information systems, hospital records, population and housing censuses, sample and household surveys, facility-based surveys, vital statistics systems, and population registers. These are all key examples of existing data collection mechanisms important for global surgery data collection. Each is presented in more detail below (Fig. 3). Given the interrelationship between surgery and the wider health and social development of nations, other indicators, including demographic, socio-economic, and financial indicators, are important to better understand surgical care and the needs of populations within these contexts. Examples include population distribution by age, sex, geography, population density, geospatial information on health facilities, gross domestic product per capita, infrastructure development, electricity, water supply, health expenditure, and out-of-pocket cost of surgery insurance systems.
Data sources for surgery statistics can be divided into two categories: 1) facility-based data such as hospital and facility records and individual patient records and 2) population-based approaches, including population and housing censuses, civil registration and vital statistics, and population sample surveys.
Data collection approaches may fit both categories of sources and provide important information that may not be available elsewhere—i.e., research and information by community-based organizations and professional medical associations. Patient-level data, including information on the patient demographics, diagnosis, and treatment, serve as the basis for clinical decision-making. Population-level data are essential for public health decision-making and can generate information not only about those who use health services but also about those who do not use them and why. Health facility-level data, from both aggregated facility-level data and administrative data sources, enable healthcare managers to determine resource needs; guide purchasing decisions for medications, equipment, and supplies; and develop community outreach. Such data can provide immediate and ongoing information relevant to public health decision-making, especially if data are of high quality, representative of the services available to the population as a whole, and related to all facilities (i.e., public, non-state actor or privately driven).28 Health information systems (HIS) refer to any system that captures, stores, manages, or transmits information related to the health of individuals or the activities of organizations that work within the health sector. These HIS are essential for monitoring and evaluation, providing an alert and early warning capability, supporting patient and health facility management, enabling planning, supporting and stimulating research, permitting health situation and trends analysis, supporting global reporting, and underpinning communication of health challenges to diverse users. A good HIS brings together all relevant partners to ensure that users have access to reliable, official, useable, understandable, and comparable data.28
Facility records include a variety of types of medical notes entered by healthcare professionals over time, recording observations and administration of medication and therapies, laboratory test results, radiology and other medical reports, orders for the administration of drugs and therapies, and other miscellaneous records. Facility records are traditionally compiled and maintained by healthcare providers in the hospital and clinics. Yet, advances in internet or web-based data storage have led to the development of personal health records, sometimes maintained by patients themselves. Facility-based patient exit surveys are an excellent source for collecting information on the true out-of-pocket cost for surgical procedures (i.e., indicators 5 and 6).
Electronic medical records provide the opportunity for healthcare organizations and institutions to improve the quality of patient care and safety and also have the potential to reduce costs and improve efficiency of the workplace.29 The use of electronic records has distinct advantages over paper records, including enabled access to medical records from remote locations and improved speed and ease of retrieval of records, research, and avenues to flag abnormal results.30
Population and housing censuses
The most comprehensive source of population data in most countries is the population census. Censuses generally provide population numbers, household or family size and composition, and information on sex and age distribution. They often include other demographic, economic, and health-related topics as well. The unique advantage of the census is that it represents the entire statistical universe, down to the smallest geographical unit, of a country or region. Further, the census is usually the starting point for household surveys. Nevertheless, it is not common practice in a census to ask questions related to surgery. Globally, as of right now, surgery is not classified as a core topic in international census recommendations, and there is no recommendation on the inclusion of a question on need for surgery in population censuses.31
Population registers can be described as a mechanism of continuous recording of selected information pertaining to each member of the resident population of a country to provide up-to-date information concerning the size and characteristics of that population. Population registers have become an important source of information for various statistical surveys, including the population census. Basic characteristics that may be included in a population register are date and place of birth, sex, date and place of death, date of arrival/departure, citizenship(s), and marital status, which are important indicators for baseline assessments regarding surgery globally.31
Several standardized international sample surveys have been designed for special purposes. Household surveys, such as the Demographic and Health Survey (DHS),32 Multiple Indicator Cluster Survey,33 and Integrated Household Survey, have become a primary source of data in developing countries. Yet, household surveys are important everywhere as they are the most reliable data source to measure indicators related to health, nutrition, and other health factors on children, women, and men.28 Compared with population censuses (and administrative registers), sample surveys can go into far greater depth and ask many more questions.
Household surveys, in fact, could provide a useful source of detailed information on the characteristics and situations of populations in need of surgical treatment. In some surveys, verbal autopsy has been used to gather health information about a deceased individual to determine cause of death (i.e., cases related to maternal deaths). The advantage of these existing surveys is that they both cover a wide range of countries and are conducted in a regular, standardized, and systematic manner. It is absolutely feasible and desirable to integrate specifically designed question modules that represent anesthesia-surgical indicator categories (i.e., preparedness, delivery, and outcomes such as financial risk protection) into these surveys to study population-level surgery and anesthesia demand and supply. A pilot on surgical questions is currently underway in the DHS survey in Zambia this year.
Health facility assessments
The WHO emergency and essential surgical care program’s situational analysis tool (WHO-SAT) was developed to evaluate the readiness of facilities to provide surgical care.34 This tool has been implemented in numerous settings worldwide over the past ten years and has subsequently been revised by the Harvard Medical School Program in Global Surgery and Social Change.34,35
Data pertinent to a country’s health service delivery, including surgical delivery, are also collected in the Service Provision Assessment (SPA) survey developed by ICF International (Fairfax, VA, USA) under the United States Agency for International Development-funded DHS program. The key services and topics assessed in a SPA survey are: infrastructure, resources, systems, child health, maternal and newborn health, family planning, human immunodeficiency virus/acquired immunodeficiency syndrome, sexually transmitted infections, malaria, tuberculosis, basic surgery, and non-communicable diseases.36
Subsequently drawing on experiences from the SPA, the WHO has developed another comprehensive tool, the SARA.37 This survey includes ample data relevant to surgery. Service availability is assessed by the collection of indicators in the three categories of health infrastructure, health workforce, and health utilization. Service readiness is assessed from tracer indicators in the five domains: 1) staff and guidelines, 2) diagnostics, 3) medicines and commodities, and 5) equipment and diagnostics. The Emergency and Essential Surgical Care program at WHO is currently involved in the process of compiling a new Health Facility Assessment tool using key items from SARA, SPA, and many of the current disease-specific tools. The WFSA have developed an anesthesia facility assessment tool, some of which will be integrated into SARA but will also be available as a stand-alone (www.wfsahq.org/afat).
Vital statistics systems
Components of a vital statistics systems refer to legal registration and statistical reporting as well as the collection, compilation, and dissemination of statistics pertaining to vital events (including events concerning life and death of individuals as well as their family and civil status). The vital events of interest to surgery and anesthesia are: live births, deaths, and maternal and fetal deaths.31 The quality of demographic and epidemiologic data depends on the extent to which countries have a functioning system of vital statistics. Monitoring the status of vital statistics is the first step to guiding and assisting those in need. Vital statistics are not always available for all countries in the world. Many LMICs have only rudimentary systems, which cannot fulfill statistical or legal purposes. For some, basic birth and death statistics can only be obtained from other tools, such as sample surveys and projection models. This may be a place to focus education and training as well as workforce expansion.
This report has highlighted the challenges faced when assessing surgical disease patterns. It has also addressed issues of access, quality, and financing of surgical and anesthesia services and related systems worldwide.
There is much to be gained from improved international coordination on global surgery and anesthesia data collection that would enable high-quality standards for obtaining official statistics. Limited global, regional, or country-specific coordination results in incoherent support, major funding gaps, or duplicative funding of specific tasks, indirectly encouraging countries to postpone critical decisions and progress.
Another consequence is the over scheduling of scarce host-country resources to service multiple data collection efforts, resulting in poorly sequenced activities, lost institutionalization opportunities, and collection of data of compromised quality. These issues have become more severe with the increasing scarcity of financial resources in support of statistical activities worldwide and non-standardized external global surgery collaborative efforts. Cooperation among National Statistical Offices, Ministries of Health, health facilities, providers, professional societies, non-governmental organizations, academia, and international organizations is necessary to ensure comprehensive and appropriate data collection and utilization.
International organizations such as the WHO, the World Bank, and national and international non-governmental organizations should ideally encourage and assist countries in collecting global surgery data. Greater investments are needed to improve data collection at the national level.
A set of standardized guidelines for the collection of surgical indicators is crucial to allow both governments and international organizations to improve data collection methods, data reporting, disaggregation, and overall data quality. Such guidelines would offer benefits to both national and international actors in charge of collection and distribution of surgical data in terms of accuracy and compatibility of data. Consensus on such indicators by a group of experts from national statistical authorities, line ministries, international organizations, and academia who are working in this area under the leadership of the WHO Emergency and Essential Surgical Care program would be the most effective way to drive progress forward. The guidelines need to make evident how the collected data will benefit all levels of decision makers, clinicians, hospital boards, politicians at the regional or national level, global organizations, and non-state actors. The message that the benefits outweigh the risks for damage to national prestige must be emphasized.
As progress is made in strengthening health information systems and surgical care delivery, indicators could be further refined to focus on other critical areas including outcomes monitoring, additional aspects of safety, unmet needs, and human impact that are not included in the current indicator set (Table 1) because of concerns about the current feasibility of collecting the supporting data.
There is currently no forum or event that allows discussion centred on global surgery and anesthesia statistics and analysis. An international conference or seminar, focusing on evaluation of the state of global surgery data collection with respect to these statistics, is vital in this regard. Such a conference could bring together experts and interested parties from national statistical offices, Ministries of Health, international and non-governmental organizations, academia, and industry.
More data collection and analyses are needed in domains such as identifying the unmet need for and inequalities in access to surgical and anesthetic care at the global, national, and sub-national levels. Data collection also needs to address barriers to seeking care at the individual level, the related types of surgical disease, quality of surgical care, and sub-national distribution in access to these services. Equally important is to register the unmet need and barriers to the data collection itself. The international community has come a long way in the past ten years in both suggesting indicators and attempting data measurement, consolidation, and improvement in health statistics. Now is the time to strive for an international consensus and inclusion of surgical and anesthesia data collection at all levels of international health information systems. Building on lessons learned and experiences of individual countries, as well as responding to new global development frameworks, strategies need to be designed to strengthen national capacity to generate, analyze, and utilize high-quality, relevant, and disaggregated global anesthesia-surgery statistics to inform health system strengthening and sustainable development for the public good. Health statistics are typically implemented as a sectoral project, not as integral part of the statistical ecosystem, which may lead to underfunding. Sustainable financing mechanisms need to be put in place to support LMICs in setting up robust systems. Limited capacity further contributes to poor data collection, delays in release of data, and limited in-depth analysis or exploitation of such data. Long-term capacity-strengthening activities need to integrate components to strengthen institutional capacity as well as institutional partnerships and coordination at the regional, national, and sub-national level. Incentives need to be provided to improve knowledge management and sharing.
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Conflict of interest
The authors declare no conflicts of interest.
This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.
Sabrina Juran originally conceived of the article and its structure and co-wrote the initial drafts. Magdalena Gruendl helped with significant contributions to the manuscript, including concepts, structure, and wording, and also co-wrote initial drafts and formatted references. Isobel H. Marks helped with significant contributions to the manuscript, including concepts, structure, and wording, and also co-wrote initial drafts. P. Niclas Broer, Jose Miguel Guzman, Justine Davies, Mark Shrimer, Walter Johnson, Hampus Holmer, Gregory Peck, Emmanuel Makasa, Lars Hagander, Stephanie J. Klug, John G. Meara, and Adrian W. Gelb helped with significant contributions to the manuscript, including concepts, structure, and wording. These authors also reviewed the draft. David Ljungman originally conceived of the article and its structure and co-wrote the initial drafts.
David Ljungman is funded by the Fulbright Commission, Swedish Medical Society, Björnsson Foundation, Sweden-America Foundation, and Adlerberth Research Foundation. John G. Meara is supported by an unrestricted grant from General Electric Foundation.
This article is accompanied by an editorial. Please see Can J Anesth 2018; 65: this issue.
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Juran, S., Gruendl, M., Marks, I.H. et al. The need to collect, aggregate, and analyze global anesthesia and surgery data. Can J Anesth/J Can Anesth 66, 218–229 (2019). https://doi.org/10.1007/s12630-018-1261-5