ArticlesAn estimation of the global volume of surgery: a modelling strategy based on available data
Introduction
Worldwide public-health initiatives have traditionally focused on surveillance and control of infectious disease, education, health promotion, and disease prevention. In recent decades, however, gains in life expectancy have changed previous trends of disease in low-income and middle-income countries, especially in the Middle East and Asia. With the so-called epidemiological transition that has accompanied industrialisation,1 disorders afflicting populations are shifting from diseases of pestilence and infection that are an indicator of pre-industrial societies to those that are identified in industrialised and rising economies.2, 3 Ischaemic heart disease, cerebrovascular disease, cancers, and mental illness have all risen substantially in low-income, middle-income, and high-income countries.4 Injuries also account for a large and growing amount of the disease burden as vehicular traffic and technical innovation increase around the world.5 These trends are bound to continue.
Surgical services have long been recognised to be an essential if often expensive component of the public-health system. Surgery occurs in every setting from the most resource rich to the most resource limited, and the need has increased greatly with the shifting patterns of disease. However, little is known about the actual worldwide volume and availability of surgical care since only anecdotal evidence exists.
Because of this epidemiological transition, surgery will assume an increasing role in public health. In view of its complexity and risks, an understanding of the quantity and distribution of surgical interventions is therefore essential to guide efforts to improve its safety and redress shortages of such services. As part of WHO's patient safety programme,6 we aimed to estimate the number of major operations undertaken worldwide, to describe their distribution, and to assess the importance of surgical care in global public-health policy.
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Population and health databases
We gathered population and health data from WHO and the UN Population Fund. We obtained data for total population, average life expectancy, death rate from HIV/AIDS, physician density, nursing density, number of hospital beds, gross domestic product, literacy rate, percentage of the population living on less than US$1 per day, and percentage coverage of vital registration of death (which is an indication of the ability of a country's capacity to gather statistical information) from the WHO's
Results
We obtained surgical data for 56 (29%) of 192 WHO member states. Countrywide data were available for 48 countries; national totals for the remaining eight countries were extrapolated from data for a portion of the country. Of countries with countrywide data, 39 had specific data for the number of major surgical procedures from which we calculated a surgical rate on the basis of WHO population data, and nine provided rates of surgery from which we calculated the total volume of surgery for the
Discussion
We have estimated that the global volume of major surgery in 2004 was between 187·2 million and 281·2 million cases per year. This result translates into about one operation for every 25 human beings, which has substantial implications for public-health planning. It exceeds by nearly double the yearly volume of childbirth—an estimated 136 million births occurred in 200615—and is probably an order of magnitude more dangerous.16, 17, 18, 19, 20, 21, 22
Although death and complication rates after
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