Study finds wide disparities in access to surgery between rich and poor countries

Mar 2 2016

The volume of surgery has increased globally over the last decade but wide disparities in access to surgery persist between rich and poor countries, according to a study published today in the Bulletin of the World Health Organization.

The authors, based in the United States of America, found that an estimated 312.9 million operations took place globally in 2012, an increase of 38% from the estimated 226.4 million operations that occurred in 2004.

But only about 30% of the operations in 2012 were done in the 104 countries that spend less than US$ 400 on health care per capita per year, representing 5 billion people or 71% of the global population.

“Clearly there are huge disparities in the provision of surgery around the world and this points to an unmet need for surgical and anaesthetic care in many countries,” said Dr Thomas Weiser, an assistant professor of surgery at Stanford University Medical Centre. “Surgical care can be life-saving and also helps prevent long-term disability due to injuries, infections, cancers, and maternal conditions.

“In addition to the disparities in access, the safety of surgical care is of utmost concern, in light of the huge and growing volume of operations being performed annually around the world,” Weiser said.

“Our study also highlights the dearth of standardized and accessible data on surgery. Only 66 of the 194 WHO Member States actually had data on surgery. We had to extrapolate figures for the rest of the countries,” he said, adding:

Policy-makers and donors need better data on the unmet need for surgery so that they can provide adequate support for strengthening health systems.

Health expenditure was measured in terms of per capita total expenditure on health in 2012. Very low expenditure was defined as US$ 100 or less, low expenditure as US$ 101–400, middle expenditure as US$ 401–1000 and high expenditure as more than US$ 1000.

Even though the greatest increases in surgery between 2004 and 2012 occurred in very-low-expenditure countries (69% or from 394 to 666 operations per 100 000 population per year) and in low-expenditure countries (114.6% or from 1851 to 3973 operations per 100 000 population per year), discrepancies between rich and poor countries persisted.

Dr Walter Johnson, who coordinates WHO’s Emergency and Essential Surgical Care Programme, said the study was important because it raises questions as to whether countries are providing the operations that people need most.

For example, the study found that caesarean deliveries accounted for 29.6% of the total surgical volume in the very-low-expenditure countries, but only 2.7% in the 44 countries classified as high expenditure accounting for 17.7% of the global population or 1.2 billion people.

“The study findings suggest that while countries may be providing more caesarian sections per capita than a decade ago, other emergency and life-saving surgical care is simply not available for the majority of people in need in low and middle-income countries,” Johnson said.

In May 2015, the World Health Assembly unanimously passed resolution 68.15: Strengthening of emergency and essential surgical care and anaesthesia as a component of universal health coverage. It called on countries to incorporate surgical care into their health systems as “a step towards providing universal health coverage”.

Last year the results of the Lancet Commission on Global Surgery were published, highlighting the lack of access to surgery globally, the often catastrophic financial consequences of out-of-pocket payments for surgical care, and the resulting improvements in national economies in countries that make a modest investment in surgical services.

“The international donor community has traditionally focused on infectious diseases,” Johnson said. “But now the shift in the burden of disease is from communicable diseases to noncommunicable conditions and injuries. These are, of course, conditions that require more surgical procedures.”