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Assessing the Brazilian surgical system with six surgical indicators: a descriptive and modelling study
  1. Benjamin B Massenburg1,2,3,
  2. Saurabh Saluja2,3,4,
  3. Hillary E Jenny1,2,3,
  4. Nakul P Raykar2,3,5,
  5. Josh Ng-Kamstra2,3,6,
  6. Aline G A Guilloux7,
  7. Mário C Scheffer7,
  8. John G Meara2,3,
  9. Nivaldo Alonso8,
  10. Mark G Shrime2,9
  1. 1Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  2. 2Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
  3. 3Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
  4. 4Department of Surgery, Weill Cornell Medicine, New York, New York, USA
  5. 5Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  6. 6Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  7. 7Departamento de Medicina Preventiva, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
  8. 8Departamento de Cirurgia Plástica, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
  9. 9Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
  1. Correspondence to Dr Mark G Shrime; shrime{at}


Background Brazil boasts a health scheme that aspires to provide universal coverage, but its surgical system has rarely been analysed. In an effort to strengthen surgical systems worldwide, the Lancet Commission on Global Surgery proposed a collection of 6 standardised indicators: 2-hour access to surgery, surgical workforce density, surgical volume, perioperative mortality rate (POMR) and protection against impoverishing and catastrophic expenditure. This study aims to characterise the Brazilian surgical health system with these newly devised indicators while gaining understanding on the complexity of the indicators themselves.

Methods Using Brazil's national healthcare database, commonly reported healthcare variables were used to calculate or simulate the 6 surgical indicators. Access to surgery was calculated using hospital locations, surgical workforce density was calculated using locations of surgeons, anaesthesiologists and obstetricians (SAO), and surgical volume and POMR were identified with surgical procedure codes. The rates of protection against impoverishing and catastrophic expenditure were modelled using cost of surgical inpatient hospitalisations and a γ distribution of incomes based on Gini and gross domestic product/capita.

Findings In 2014, SAO density was 34.7/100 000 population, surgical volume was 4433 procedures/100 000 people and POMR was 1.71%. 79.4% of surgical patients were protected against impoverishing expenditure and 84.6% were protected against catastrophic expenditure due to surgery each year. 2-hour access to surgery was not able to be calculated from national health data, but a proxy measure suggested that 97.2% of the population has 2-hour access to a hospital that may be able to provide surgery. Geographic disparities were seen in all indicators.

Interpretation Brazil's public surgical system meets several key benchmarks. Geographic disparities, however, are substantial and raise concerns of equity. Policies should focus on stimulating appropriate geographic allocation of the surgical workforce and better distribution of surgical volume. In some cases, where benchmarks for each indicator are met, supplemental analysis can further inform our understanding of health systems. This measured and systematic evaluation should be encouraged for all nations seeking to better understand their surgical systems.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • BBM and SS are co-first authors.

  • NA and MGS are co-last authors.

  • Handling editor Valery Ridde.

  • Twitter Follow Benjamin Massenburg @bbmassenburg, Saurabh Saluja @newvernacular, Joshua Ng-Kamstra @joshngkamstra, John Meara @JohnMeara and Mark Shrime @markshrime

  • Contributors BBM and SS were involved in literature search, figures, study design, data collection, data analysis, data interpretation and writing. HEJ and JN-K were involved in literature search, data analysis, data interpretation and writing. NPR, AGAG and MCS were involved in literature search, data analysis and data interpretation. JGM, NA and MGS were involved in study design, data analysis, data interpretation and writing.

  • Funding MGS receives grant support from the GE Foundation Safe Surgery 2020 Project and from the Steven C. and Carmella Kletjian Foundation.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.