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Geospatial mapping of access to timely essential surgery in sub-Saharan Africa
  1. Sabrina Juran1,2,
  2. P. Niclas Broer3,
  3. Stefanie J. Klug2,
  4. Rachel C. Snow1,
  5. Emelda A. Okiro4,
  6. Paul O. Ouma4,
  7. Robert W. Snow4,
  8. Andrew J. Tatem5,6,
  9. John G. Meara7,
  10. Victor A. Alegana5,6
  1. 1 United Nations Population Fund, Technical Division, Population and Development Branch, New York City, New York, USA
  2. 2 Lehrstuhl für Epidemiologie, Technische Universität München, München, Germany
  3. 3 Klinikum Bogenhausen, Städtisches Klinikum München, Technische Universität München, München, Germany
  4. 4 Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
  5. 5 WorldPop, Geography and Environment, University of Southampton, Southampton, UK
  6. 6 Flowminder Foundation, Stockholm, Sweden
  7. 7 Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr. Sabrina Juran; sabrinajuran{at}


Introduction Despite an estimated one-third of the global burden of disease being surgical, only limited estimates of accessibility to surgical treatment in sub-Saharan Africa exist and these remain spatially undefined. Geographical metrics of access to major hospitals were estimated based on travel time. Estimates were then used to assess need for surgery at country level.

Methods Major district and regional hospitals were assumed to have capability to perform bellwether procedures. Geographical locations of hospitals in relation to the population in the 47 sub-Saharan countries were combined with spatial ancillary data on roads, elevation, land use or land cover to estimate travel-time metrics of 30 min, 1 hour and 2 hours. Hospital catchment was defined as population residing in areas less than 2 hours of travel time to the next major hospital. Travel-time metrics were combined with fine-scale population maps to define burden of surgery at hospital catchment level.

Results Overall, the majority of the population (92.5%) in sub-Saharan Africa reside in areas within 2 hours of a major hospital catchment defined based on spatially defined travel times. The burden of surgery in all-age population was 257.8 million to 294.7 million people and was highest in high-population density countries and lowest in sparsely populated or smaller countries. The estimated burden in children <15 years was 115.3 million to 131.8 million and had similar spatial distribution to the all-age pattern.

Conclusion The study provides an assessment of accessibility and burden of surgical disease in sub-Saharan Africa. Yet given the optimistic assumption of adequare surgical capability of major hospitals, the true burden of surgical disease is expected to be much greater. In-depth health facility assessments are needed to define infrastructure, personnel and medicine supply for delivering timely and safe affordable surgery to further inform the analysis.

  • spatial modelling
  • geospatial analysis
  • catchment population
  • global surgery
  • universal health coverage
  • sub-Saharn Africa

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  • Handling editor Seye Abimbola

  • Contributors SJ, VAA and AJT conceived and designed the study. SJ and VAA were responsible for data management, analysis and production of the first draft of manuscript. PNB, SJK, EAO, POO, JGM reviewed and edited drafts of the manuscript. All authors reviewed, edited and approved the final manuscript.

  • Funding AJT is supported by a Wellcome Trust Sustaining Health Grant (no. 106866/Z/15/Z) and Bill & Melinda Gates Foundation (nos. OPP1106427, 1032350, OPP1134076). RWS is supported by the Wellcome Trust as Principal Research Fellow (no. 103602) that part supported POO.

  • Competing interests None declared.

  • Patient consent Not required.

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

  • Data sharing statement A full database of hospital location data is available open access through the Harvard Dataverse under a CC-BY 4.0 license. All the ancillary spatial datasets and are available online.

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