Is still surgery ‘the neglected stepchild of global health’?

Over two-thirds of the world’s population lack access to surgical care.

Improving access to surgical care is essential, since surgery can successfully treat a wide variety of conditions including cancers, injuries, infectious diseases, pregnancy-related complications…

However, many people do not currently have access to safe, timely and affordable surgical care and anaesthesia worldwide. In many areas of the world, most people cannot access even the most basic surgical services. Through universal access to safe, timely and affordable surgery, we could save many lives, prevent disability and also promote economic growth as a result.

On 22 May 2015, the 68th World Health Assembly unanimously passed resolution 68.15 on strengthening emergency and essential surgical and anaesthesia care as a component of universal health coverage. This  resolution  urges  countries  to  prioritize  surgical  and  anaesthesia  care as part of national health plans, emphasizing the importance of service delivery, quality, training, workforce, infrastructure and data collection to support monitoring and evaluation.

To begin to address these crucial gaps in knowledge, policy, and action, The Lancet Commission on Global Surgery (LCoGS) was launched basing on five key messages.

  • Approximately 5 billion people do not have access to safe, affordable surgical and anesthesia care when needed. Access is worst in low-income and middle-income countries (LMICs), where nine of 10 people cannot access basic surgical care.
  • An additional 143 million surgical procedures are needed in LMICs each year to save lives and prevent disability. Of the 313 million procedures undertaken worldwide each year, only 6 percent occur in the poorest countries, where more than a third of the world’s population lives. Low operative volumes are associated with high case-fatality rates from common, treatable surgical conditions. Unmet need is greatest in eastern, western, and central sub-Saharan Africa and south Asia.
  • An estimated 33 million individuals face catastrophic health expenses to pay for surgical and anesthesia care each year. An additional 48 million cases of catastrophic expenditure are attributable to the nonmedical costs of accessing surgical care such as transportation, lodging, and food. A quarter of the people who have a surgical procedure will incur financial catastrophe as a result of seeking care. The burden of catastrophic expenditure for surgery is highest for LMICs and, within any country, lands most heavily on poor people.
  • Investing in surgical services in LMICs is affordable, saves lives, and promotes economic growth. To meet present and projected population demands, urgent investment in human and physical resources for surgical and anesthesia care is needed. If LMICs were to scale up surgical services at rates achieved by the present best-performing LMICs, two-thirds of countries would be able to reach a minimum operative volume of 5,000 surgical procedures per 100,000 population by 2030. Without urgent and accelerated investment in surgical scale-up, LMICs will continue to have losses in economic productivity, estimated cumulatively at $12.3 trillion (2010 U.S. dollars, purchasing power parity) between 2015 and 2030.
  • Surgery is an “indivisible, indispensable part of health care.”‡ Surgical and anesthesia care should be an integral component of a national health system in countries at all levels of development. Surgical services are a prerequisite for the full attainment of local and global health goals in areas as diverse as cancer, injury, cardiovascular disease, infection, and reproductive, maternal, neonatal, and child health. Universal health coverage and the health aspirations set out in the post-2015 sustainable development goals (SDGs) will be impossible to achieve without ensuring that surgical and anesthesia care is available, accessible, safe, timely, and affordable.

The LCoGS recommended the measurement of six key indicators necessary to assess a country’s surgical system. These indicators of a surgical system are as follows:

  • Two-hour access to a facility offering surgical services
  • Surgical workforce density
  • Surgical volume
  • Perioperative mortality rate
  • Protection against impoverishing expenditure
  • Protection against catastrophic expenditure

In 2016, the Harvard Program in Global Surgery and Social Change, a research program focused on the role of surgery and its impact on impoverished health systems and contributor to the third edition of Disease Control Priorities and the LCoGS report, partnered with the Zambian Ministry of Health to take the theoretical framework developed by the LCoGS and implement it. Specifically, the goal was to create Zambia’s first National Surgical, Obstetric, and Anesthesia Strategic Plan (NSOASP), the first major policy document at the time focused on global surgical systems.

The Lancet Commission on Investing in Health pointed to ‘the possibility of achieving dramatic gains in global health by 2035 through a grand convergence around infectious, child, and maternal mortality; major reductions in the incidence and consequences of non-communicable diseases and injuries; and the promise of universal coverage’.

Probably this lofty goal will not be achieved without the provision of safe, accessible, affordable and essential surgical services.


Meara JG, Leather AJ, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569–624.

Debas HT. Access to safe surgery. BMJ Glob Health. 2018 May 21;2(Suppl 4):e000908.