Summary box

• Currently, five billion people lack access to safe, timely and affordable surgical and anaesthesia care; in low-resource settings, nine of ten people cannot access basic surgical services.

• Up until the mid-20th century the emphasis from the donor countries towards the low-income and middle-income countries (LMICs) had been a ‘top down’ approach of providing full-scale hospital facilities with doctors and nurses, including some tertiary referral centres.

• The ‘bottom up’ approach (which informed the Alma Ata Declaration) was developed from the experience of Feldshers in USSR, rural-based, minimally trained community healthcare workers, and from China’s ‘barefoot doctors’ that included community participation in the rural health services.

• But even though the place of essential surgery in PHC was recognised by WHO DG Halfdan Mahler in 1980, the surgical speciality has largely been neglected by the global public health community, partly because of the false arguments that surgical care is too expensive.

• Surgical and anaesthesia care should be considered as investments rather than costs; they are integral to making universal health coverage a reality - 40 years after the Alma Ata Declaration, it is time to effectively integrate PHC and surgical care globally and locally.