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How much does it cost to scale up surgical systems in low-income and middle-income countries?
  1. Desmond T. Jumbam1,2,
  2. Ché Len Reddy1,2,
  3. Lina Roa1,3,
  4. John G. Meara1,2
  1. 1Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
  2. 2Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
  3. 3Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
  1. Correspondence to Mr Desmond T. Jumbam; desmond.jumbam{at}

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Poor access to safe, affordable and timely surgical, obstetric and anaesthesia (SOA) care remains a major cause of global morbidity and mortality, impacting low-income and middle-income countries (LMICs) most severely. Globally, approximately five billion people lack access to safe, affordable and timely SOA care. This accounts for about a third of the global burden of disease and drives close to 81 million people into catastrophic expenditure each year.1 In 2010, an estimated 16.9 million deaths worldwide, a third of all deaths, were attributable to surgical conditions.1 2 Annually, about 77.2 million disability-adjusted life years in LMICs could be averted with investments in basic, life-saving high quality SOA care.3

A major impediment to scaling surgical systems in resource-limited settings has been the notion that the cost is too high and the planning and orchestration too complex. SOA care systems require a functioning operating theatre along with specialised workforce, nurses, biomedical engineers, reliable supply chain systems for consumables and medicines, dependable blood banks, diagnostics, strong prehospital and referral systems and postoperative care. As Farmer and Kim succinctly put it, “there is no surgical equivalent to a vaccination campaign or a mosquito net”.4 This apparent complexity and the associated costs have made policy-makers reticent to invest in surgical systems, despite the need for these services to achieve the Sustainable Development Goals (SDG) and Universal Health Coverage (UHC).5

Since 2015, notable progress has been made at both global and national levels. At the global level, surgical and anaesthesia care has been explicitly acknowledged as an essential component of UHC by all Member States of the World Health Assembly through Resolution 68.15.6 This commitment was recently re-emphasised in a recent address by Dr Tedros Adhanom Ghebreyesus, Director General of the WHO, who stated that “no country can achieve universal health coverage unless its …

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