Elsevier

The Lancet

Volume 385, Issue 9983, 30 May–5 June 2015, Pages 2209-2219
The Lancet

Review
Essential surgery: key messages from Disease Control Priorities, 3rd edition

https://doi.org/10.1016/S0140-6736(15)60091-5Get rights and content

Summary

The World Bank will publish the nine volumes of Disease Control Priorities, 3rd edition, in 2015–16. Volume 1—Essential Surgery—identifies 44 surgical procedures as essential on the basis that they address substantial needs, are cost effective, and are feasible to implement. This report summarises and critically assesses the volume's five key findings. First, provision of essential surgical procedures would avert about 1·5 million deaths a year, or 6–7% of all avertable deaths in low-income and middle-income countries. Second, essential surgical procedures rank among the most cost effective of all health interventions. The surgical platform of the first-level hospital delivers 28 of the 44 essential procedures, making investment in this platform also highly cost effective. Third, measures to expand access to surgery, such as task sharing, have been shown to be safe and effective while countries make long-term investments in building surgical and anaesthesia workforces. Because emergency procedures constitute 23 of the 28 procedures provided at first-level hospitals, expansion of access requires that such facilities be widely geographically diffused. Fourth, substantial disparities remain in the safety of surgical care, driven by high perioperative mortality rates including anaesthesia-related deaths in low-income and middle-income countries. Feasible measures, such as WHO's Surgical Safety Checklist, have led to improvements in safety and quality. Fifth, the large burden of surgical disorders, cost-effectiveness of essential surgery, and strong public demand for surgical services suggest that universal coverage of essential surgery should be financed early on the path to universal health coverage. We point to estimates that full coverage of the component of universal coverage of essential surgery applicable to first-level hospitals would require just over US$3 billion annually of additional spending and yield a benefit–cost ratio of more than 10:1. It would efficiently and equitably provide health benefits, financial protection, and contributions to stronger health systems.

Introduction

Disorders that are treated mainly or frequently by surgery constitute a substantial portion of the global burden of disease. Each year, injuries kill nearly 5 million people and about 270 000 women die from complications of pregnancy.1 Many of these injury-related and obstetric-related deaths, as well as deaths from other causes (eg, abdominal emergencies and congenital anomalies), could be prevented by improved access to surgical care.

Despite this large burden, surgical services are not being delivered to many of the individuals who need them most. An estimated 2 billion people lack access to even the most basic of surgical care.2 This need has not been widely acknowledged, and priorities for investment in health systems' surgical capacities have therefore only recently been investigated. Indeed, until the 1990s, health policy in resource-constrained settings focused sharply on infectious diseases and undernutrition, especially in children. Surgical capacity was developing in urban areas but was often viewed as a secondary priority that mainly served socioeconomically advantaged people.

In the 1990s, several studies began to question the perception that surgery was costly and low in effectiveness. Economic evaluations of cataract surgery showed the procedure to be cost effective even under resource-constrained circumstances; Javitt3 pioneered cost-effectiveness analysis for surgery, including his chapter on cataract in the first edition of Disease Control Priorities in Developing Countries in 1993. In 2003, McCord and Chowdhury4 enriched the approach to economic evaluation in surgery in a report assessing the overall cost-effectiveness of a surgical platform in Bangladesh. The design of Disease Control Priorities in Developing Countries, 2nd edition (DCP2), published in 2006, placed much more substantial emphasis on surgery than had previous health policy documents. DCP2 included a dedicated chapter on surgery that amplified the approach of McCord and Chowdhury and provided an initial estimate of the amount of disease burden that could be addressed by surgical intervention in low-income and middle-income countries. The design of the Disease Control Priorities, 3rd edition (DCP3), places still-greater emphasis on surgery by dedication of an entire volume (out of nine in total) to the topic. There is also a growing academic literature on surgery's importance in health system development—for example, as described by Paul Farmer and Jim Kim,5 who noted that “surgery may be thought of as the neglected stepchild of global public health”. Likewise, WHO is paying increasing attention to surgical care, such as through its Global Initiative for Emergency and Essential Surgical Care.6 Finally, the creation of a Lancet Commission on Global Surgery,7 now well into its work, points to a major change in the perceived importance of surgery.

This report summarises the main findings of Essential Surgery.8 We attempt to better define the health burden of disorders requiring surgery, identify those surgical procedures that are the most cost effective and cost beneficial, and describe the health-care policies and platforms that can universally deliver these procedures at high quality. In particular, Essential Surgery seeks to define and study a package of so-called essential surgical procedures that would lead to substantial improvements in health if they were universally delivered (ie, universal coverage of essential surgery). This report and the volume focus on the situation in low-income and lower-middle-income countries. In a companion Comment, Dean Jamison9 discusses the history, objectives, and contents of DCP3, of which Essential Surgery constitutes Volume 1.xx.

Section snippets

Definitions

Health disorders cannot be neatly dichotomised into disorders that need surgery and those that do not. Different diagnoses range widely in the proportion of patients who need some type of surgical procedure. At the upper end are admissions for musculoskeletal disorders (84% of which involved some type of surgical procedure in an operating room in the USA in 2010) and at the lower end are admissions for mental health disorders (0·4%).10

The surgical capabilities required are not only those

Overview

This report synthesises the main results of the individual chapters of Essential Surgery to provide broad directions for policy. The key messages deriving from our analysis are summarised and explained in further detail below, concerning five categories of results: surgically avertable disease burden, cost-effectiveness and economics, improvements to access, improvements to quality, and essential surgery in the context of universal health coverage. The appendix lists the titles, authors, and

Conclusions

There is a high burden of avertable death and disability from disorders that can be successfully treated by surgery. Many of the surgical procedures and capabilities needed to treat these disorders are among the most cost effective of all health interventions and most in demand from the population. These interventions include procedures to treat injuries, obstetric complications, abdominal emergencies, cataracts, obstetric fistula, and congenital anomalies. Many of the most needed procedures

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