The Lancet, Volume 386, 8 August 2015,
Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world's poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, non-communicable diseases, and injuries. Surgical and anaesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffi c injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anaesthesia care, which should be available, aff ordable, timely, and safe to ensure good coverage, uptake, and outcomes. Despite growing need, the development and delivery of surgical and anaesthesia care in LMICs has been nearly absent from the global health discourse. Little has been written about the human and economic eff ect of surgical conditions, the state of surgical care, or the potential strategies for scale-up of surgical services in LMICs. To begin to address these crucial gaps in knowledge, policy, and action, the Lancet Commission on Global Surgery was launched in January, 2014. The Commission brought together an international, multidisciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents. We formed four working groups that focused on the domains of health-care delivery and management; workforce, training, and education; economics and fi nance; and information management. Our Commission has fi ve key messages, a set of indicators and recommendations to improve access to safe, aff ordablesurgical and anaesthesia care in LMICs, and a template for a national surgical plan. Our fi ve key messages are presented as follows: 5 billion people do not have access to safe, aff ordable surgical and anaesthesia care when needed. Access is worst in low-income and lower-middle-income countries, where nine of ten people cannot access basic surgical care. 143 million additional surgical procedures are needed in LMICs each year to save lives and prevent disability. Of the 313 million procedures undertaken worldwide each year, only 6% occur in the poorest countries, where over a third of the world's population lives. Low operative volumes are associated with high case-fatality rates from common, treatable surgical conditions. Unmet need is greatest in eastern, western, and central sub-Saharan Africa, and south Asia. 33 million individuals face catastrophic health expenditure due to payment for surgery and anaesthesia care each year. An additional 48 million cases of catastrophic expenditure are attributable to the nonmedical costs of accessing surgical care. A quarter of people who have a surgical procedure will incur fi nancial catastrophe as a result of seeking care. The burden of catastrophic expenditure for surgery is highest in low-income and lower-middle-income countries and, within any country, lands most heavily on poor people. Investing in surgical services in LMICs is aff ordable, saves lives, and promotes economic growth. To meet present and projected population demands, urgent investment in human and physical resources for surgical and anaesthesia care is needed. If LMICs were to scale-up surgical services at rates achieved by the present best-performing LMICs, two-thirds of countries would be able to reach a minimum operative volume of 5000 surgical procedures per 100 000 population by 2030. Without urgent and accelerated investment in surgical scale-up, LMICs will continue to have losses in economic productivity, estimated cumulatively at US $12.3 trillion (2010 US$, purchasing power parity) between 2015 and 2030. Surgery is an "indivisible, indispensable part of health care."1 Surgical and anaesthesia care should be an integral component of a national health system in countries at all levels of development. Surgical services are a prerequisite for the full attainment of local andglobal health goals in areas as diverse as cancer, injury, cardiovascular disease, infection, and reproductive, maternal, neonatal, and child health. Universal health coverage and the health aspirations set out in the post-2015 Sustainable Development Goals will be impossible to achieve without ensuring that surgical and anaesthesia care is available, accessible, safe, timely, and aff ordable. In summary, the Commission's key fi ndings show that the human and economic consequences of untreated surgical conditions in LMICs are large and for many years have gone unrecognised. During the past two decades, global health has focused on individual diseases. The development of integrated health services and health systems has been somewhat neglected. As such, surgical care has been aff orded low priority in the world's poorest regions. Our report presents a clear challenge to this approach. As a new era of global health begins in 2015, the focus should be on the development of broad-based health-systems solutions, and resources should be allocated accordingly. Surgical care has an incontrovertible, cross-cutting role in achievement of local and global health challenges. It is an important part of the solution to many diseases-for both old threats and new challenges-and a crucial component of a functional, responsive, and resilient health system. The health gains from scaling up surgical care in LMICs are great and the economic benefi ts substantial. They accrue across all disease-cause categories and at all stages of life, but especially benefi t our youth and young adult populations. The provision of safe and aff ordable surgical and anaesthesia care when needed not only reduces premature death and disability, but also boosts welfare, economic productivity, capacity, and freedoms, contributing to longterm development. Our six core surgical indicators(table 1) should be tracked and reported by all countries and global health organisations, such as the World Bank through the World Development Indicators, WHO through the Global Reference List of 100 Core Health Indicators, and entities tracking the SDGs. At the opening meeting of the Lancet Commission on Global Surgery in January, 2014, Jim Kim, President of the World Bank, stated that: "surgery is an indivisible, indispensable part of health care" and "can help millions of people lead healthier, more productive lives. In 2015, good reason exists to ensure that access to surgical and anaesthesia care is realised for all.