Current trends indicate that the global burden of disease is clearly shifting from infectious diseases to injury and non-communicable diseases (NCDs). With this rapid shift, it remains important and necessary to turn global health attention towards developing intervention programs and implementation strategies in prevention, early detection and timely intervention. However, there is still an enormous gap in the treatment options because only limited attention is being focused on surgical need, obstetrical and anesthesia care, particularly in the context of low and middle-income countries (LMICs).

The burden in stats: 

  • 5 billion: the number of people lack access to safe and essential surgery
  • 90%: the total share of the world’s poor that lack access to safe and affordable surgical care
  • 30%: The share of worldwide diseases that can be treated by surgery or require the direct care of a surgeon
  • 12 trillion USDs: The lost economic output in LMICs by the year 2030 through surgical diseases
  • 6 times: The number of surgically avertable deaths compared to HIV, malaria and TB combined

Despite the obvious need, there is presently no coordinated research or funding strategy to support the development of surgical and trauma care in LMICs, as opposed to the strategies that exist for infectious burdens such as HIV, TB and/or malaria.

Substandard infrastructure and health system:

A well-functioning surgical care system is essential and is the foundation for the treatment of injury and many of the NCD disease profiles. Health-care delivery is a complex enterprise with many interconnected parts, the following essential components stand out: trained and experienced human resources, standardized infrastructure and equipment profile, and a strong health system. Yet, evidence to date suggests that such essential components are limited, if not completely lacking in many LMIC settings. For example, an assessment of operating theater density showed that 90% of the population of sub-Saharan Africa has access to roughly one operating theater per 100 000 people. And even more unfortunate is that the few theaters that do exist have very limited capacity to provide safe surgical care. For instance, up to 70% of the aforementioned theaters lack pulse oximetry, an anesthetic monitoring standard.

Hurdles to access and financial constraints:

Furthermore, even when adequate surgical capacity and robust safety mechanisms exist, patients in low-income settings often confront numerous barriers to access. A fully equipped operating theater serves little purpose for patients who cannot reach the hospital in a timely manner, or for whom a surgical team is unavailable. Additionally, patients who do receive appropriate surgical care often risk impoverishment secondary to out-of-pocket payments.

Morbidity and Mortality Burden:

Too often in LMICs, surgical instruments are not adequately cleaned and disinfected, rendering subsequent steam sterilization ineffective. Sterility of surgical instruments is a crucial requirement in the prevention of wound infection and other septic perioperative complications that are often life-threatening. Along with this, it remains important to mention the threat of bacterial resistance to antibiotics that, as it stands, represents a major health threat globally, let alone in the context of LMICs. Research shows that there is a significant burden of bacterial resistance to wound infection to first-line antibiotics in several Sub-Saharan countries.

Mortality from surgical operations in LMICs is alarmingly high. For example, deaths from cesarean sections occur in 0.04 births per 1000 in Sweden; in sub-Saharan Africa, the death rate is 100 times higher. In parallel, deaths attributable to anesthesia are estimated to occur at a rate of 141 deaths per million in LMICs as compared to the rate of 25 per million in their high-income counterparts. Evidence suggests that most surgical deaths occur in the perioperative period, and many of these deaths are preventable by strictly implementing the 19-item WHO Surgical Checklist and closer intra- and postoperative monitoring. The use of this checklist has been shown to decrease morbidity and mortality of surgery by nearly 50%.

Surgical need: next steps

High disease burden and inadequate resources have formed the basis for advocacy to improve surgical care in LMICs thus far and current measures are heavily focused on availability of resources rather than impact. This inadvertently fails to fully describe how surgery can be more integrated into health systems. A strict and comprehensive monitoring system based on scientific suggestions and research-oriented strategic planning is crucial to ensure safer, more accessible and efficient surgical care delivery in LMICs. It is particularly important to work on improving the health system governance, as it is the glue that seeds into holding the safe and quality delivery to a global standard. Some steps in that regard include:

  • Governance of health systems in terms of consideration of policy development for district level surgical service priorities, surgical education curriculum and accreditation standards, surgical care financing, and equipment and medical supply chain.
  • Actionable set of infrastructure and budget indicators i.e. number of operating rooms and surgical inpatient beds per 100 000 people, surgical care as a percent of the total healthcare budget, numbers of practitioners in the context of the population
  • Utilization of existing epidemiological data, which is frequently used for program planning for other diseases, for the field of surgery i.e. population prevalence of surgical disease, regional variation in surgical disease burden.
  • Provision and rollout of standardized metrics for adherence to management guidelines. Prioritized interventions and provider/health facilities competency.
  • Strict employment of internal monitoring and evaluation tools: annual number of major and minor procedures performed, number of patients referred to a higher level of care and distance traveled by the average patient, mortality and morbidity conferences and review of educational resources within facilities.
  • Include surgical care within preventative public health programs by evaluating risk factors and behaviors i.e. interventions to prevent road traffic accidents or burns, antenatal care and primary healthcare worker education on surgical conditions for improved medical stabilization and quicker referrals.
Eleleta Surafel Abay, MD
Eleleta Surafel Abay, MD

Eleleta is a medical doctor based in Ethiopia. She holds several advisory positions in local and international global health initiatives. She has great passion for global health and health intervention-implementation research, and neglected diseases in low- and middle-income settings.


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