Global surgery: why access to essential surgery is important

G lobal surgery is the neglected stepchild in global health. The neglect is more shocking in South Asia which has the largest population globally lacking access to essential surgery. What is global surgery? Global surgery focuses on equitable access to emergency and essential surgery.

While it predominantly focuses on low- and middle-income countries (LMICs), it also prioritises access disparities and under-served populations in high-income countries (HICs). These “surgeries” include essential and emergency surgeries such as surgery, obstetrics, trauma, and anaesthesia (SOTA). Despite small differences, there is largely a consensus across multiple international groups on about thirty or so procedures that fall under the umbrella of emergency and essential surgery.

How far back does global surgery go? The year 2015, can be considered the “Annus Mirabilis” or the miracle year for global surgery. It proved to be an inflection point in recognising the importance of surgical care on a global scale. One key development that played a significant role in this transformation was the Disease Control Priorities Network (DCPN) report on essential surgery sponsored by the World Bank which highlighted that emergency and essential surgical care is cost-effective; scaling up surgical systems is cost-beneficial; and that there is a large disease burden that is surgically avertable.

The second development was The Lancet Commission on Global Surgery (LCoGS) which brought together experts and stakeholders to examine the status of surgical care access around the world; ideate the indicators for monitoring surgical care preparedness; systemic capacity and impact; and to develop implementable strategies such as the national surgical, obstetrics, and anaesthesia plan (NSOAP). This paved the way for arguably the most important high-level policy and political commitment to surgery, which is the passage of the World Health Organization Declaration on Safe Surgery (WHO Resolution 68. 15) which recognised the impossibility of universal health coverage in the absence of required commitment to emergency and essential surgical systems.

While 2015 set the stage for popular global surgery, it is critical to note that the history of the field as a whole goes back several decades. The exchange of knowledge and bilateral sharing of trainees under surgical missions in humanitarian settings across various parts of the world in the last century can be considered global. Given the focus on reducing disparities, people have also rightly argued that surgeons committed to delivering care in rural and remote parts of the world found global surgery several decades before 2015.

How big of a problem is it? The magnitude of problems of global surgery is substantial, encompassing a range of challenges including inaccessibility, disease burden, and economic burden. The LCoGS noted that five billion people or over 70% of the global population lack timely access to safe and affordable surgical care when needed. Most severely, 99% and 96% of the people in low- and lower-middle-income countries (LLMICs) respectively, face access gaps compared to 24% in high-income countries (HICs), which points to a glaring global disparity.

Of the five billion people, over 1. 6 billion people lacking access live in South Asia. This translates to over 98% of the South Asian population lacking access to safe and affordable SOTA care.

Lack of access is tied to disease burden. In 2010, around 17 million deaths were attributed to surgically treatable conditions, surpassing the combined mortality burden of HIV/AIDS, tuberculosis, and malaria — emphasising the need for improved access. Work from the Global Surg Collaborative has noted that peri-operative mortality is the third most common cause of death just below ischemic heart disease and stroke.

This is partly due to the lack of timely care, unsafe surgeries, and limited capacity of surgical systems. Further, the DCPN comprehensively assessed the disease burden in LMICs that can be averted by scaling up surgical services at district hospitals. It found LMICs to have over 77 million surgically avertable Disability-Adjusted Life-Years (DALY) that formed 3.

5% of the total disease burden in these countries. Among regions, South Asia had a higher DALY rate than the LMIC average. South Asia contributed to 50.

46%, 32. 49%, 26. 67%, and 33.

35% of the surgically avertable burden of neonatal and maternal diseases, congenital anomalies, digestive conditions, and injuries respectively. The disease burden also leads to an economic burden. The cumulative projected loss to GDP due to the absence of scale-up of surgical care are estimated to be $20.

7 trillion (in purchasing power parity terms) across 128 countries by 2030. The annual loss in societal welfare was about $14. 5 trillion for 175 countries.

South Asia contributes to about 7% of the global lost welfare. What is being done? Regardless of the disease and economic burden, surgery gets neglected in policies and health planning at the international level. The LCoGS noted that surgery contributed to <1% of all indicators mentioned in the World Bank, WHO, UNICEF, and other reports.

Neglect is also present in national policymaking. An analysis of National Health Strategic Plans from 43 African countries noted that 19% did not mention surgery or surgical conditions at all while 63% mentioned surgery only five times or less. Similarly, an analysis of 70+ years of policymaking in India also noted limited and decreasing attention to surgery.

The most recent National Health Policy (2017) had only two mentions of the partial phrase — “surg”. While The Lancet Commission on Global Cancer Surgery noted that surgery is central to national cancer control plans, India’s new guidelines on non-communicable diseases (2023) that focuses on cancer heavily has sparse mention of surgery. While national health account data on funding for surgery is limited, data from other sources such as the Developmental Assistance for Health (DAH) points to neglect in funding for surgery and related areas.

DAH contributions to trauma care are <$1 per DALY compared to $41 per DALY for HIV or $25 for tuberculosis. While U. S.

charitable organisations and foundations have spent several million on surgical care in LMICs, these are driven mainly toward specific diseases such as cleft palate, obstetric fistula, and ophthalmic issues, leaving strengthening surgical systems up to individual countries. For example, of the $105 million spent by 470 U. S.

foundations from 2003 to 2013, only $7. 1 million and $1. 7 million went to the training of local surgical providers, and infrastructure respectively.

Neglect is also observed in research. A cursory bibliometric analysis reveals that in 2022, there were only 315 ‘global surgery’ titles (1. 5%) in the Pubmed database compared to 21,453 ‘global health’ titles.

Research is in turn tied to research funding. For instance, the biggest research funder for healthcare in the U. S.

is the National Institutes of Health (NIH). In 2021, NIH funded 1,500 large research projects (R01 grants) worth $750 million of which only 40 projects worth $22 million were related to surgery and only one was about global surgery. Neglect in policy, financing, and research and all interrelated with one driving another.

What next? The above might present a daunting picture but challenges in global surgery are solvable. Work from LCoGS and DCPN depicted that emergency and essential surgical care is cost-effective and cost-beneficial. At least 30 LLMICs now have some subnational data on their surgical care indicators — the largest one being India.

Several African countries have drafted and implemented NSOAPs showing strong political and policy commitment since 2015. In South Asia, Pakistan has formulated a National Surgical Care Vision, Nepal has initiated an NSOAP, and the Pradhan Mantri Jan Arogya Yojana has provided millions of surgeries at zero or negligible cost to the bottom 40% of Indians. Research and innovation, policy focus, and sustained financing are key to solving global surgery challenges.

Aiman Perween Afsar and Maithili. K are researchers at the Association for Socially Applicable Research (ASAR). Siddhesh Zadey is a co-founding director of ASAR.

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