Appendix 2.A. Executive Summary of Lancet Commission on Global Surgery

Appendix 2.a. Executive summary of Lancet Commission on Global Surgery.

Global Surgery 2030: evidence and solutions for achievinghealth,welfare, and economicdevelopment

JohnG Meara*, Andrew J M Leather*, Lars Hagander*, BlakeC Alkire,Nivaldo Alonso, Emmanuel A Ameh, StephenW Bickler,LesongConteh,Anna J Dare, Justine Davies, Eunice DérivoisMérisier,Shenaaz El-Halabi, Paul E Farmer,AtulGawande, Rowan Gillies, Sarah L MGreenberg,Caris EGrimes, Russell LGruen, Edna Adan Ismail,ThaimBuya Kamara,Chris Lavy, GanboldLundeg, NyengoC Mkandawire,Nakul P Raykar,JohannaN Riesel, Edgar Rodas‡, John Rose, Nobhojit Roy, MarkG Shrime, Richard Sullivan, StéphaneVerguet, DavidWatters,ThomasGWeiser,Iain HWilson,GavinYamey,WinnieYip

Executive summary

Remarkablegainshavebeenmadeinglobalhealthinthepast25years,butprogresshasnotbeenuniform. Mortalityandmorbidityfromcommonconditionsneedingsurgeryhavegrownintheworld’spoorestregions,bothinrealtermsandrelativetootherhealth gains.Atthesametime,developmentofsafe,essential,life-savingsurgicalandanaesthesiacareinlow-income andmiddle-incomecountries(LMICs)hasstagnatedor regressed.Intheabsenceofsurgicalcare,case-fatality ratesarehighforcommon,easilytreatableconditions includingappendicitis,hernia,fractures,obstructed labour,congenitalanomalies,andbreastandcervicalcancer.

In2015,manyLMICsarefacingamultifacetedburden ofinfectiousdisease,maternaldisease,neonataldisease, non-communicablediseases,andinjuries.Surgicalandanaesthesiacareareessentialforthetreatmentofmany oftheseconditionsandrepresentanintegralcomponent ofafunctional,responsive,andresilienthealthsystem. Inviewofthelargeprojectedincreaseintheincidenceof cancer,roadtrafficinjuries,andcardiovascularandmetabolicdiseasesinLMICs,theneedforsurgical servicesintheseregionswillcontinuetorisesubstantially fromnowuntil2030.Reductionofdeathanddisabilityhingesonaccesstosurgicalandanaesthesiacare,which shouldbeavailable,affordable,timely,andsafetoensuregood coverage, uptake, and outcomes.

Despitegrowingneed,thedevelopmentanddelivery ofsurgicalandanaesthesiacareinLMICshasbeen nearlyabsentfromtheglobalhealthdiscourse.Littlehas beenwrittenaboutthehumanandeconomiceffectof surgicalconditions,thestateofsurgicalcare,orthe potentialstrategiesforscale-upofsurgicalservicesin LMICs.Tobegintoaddressthesecrucialgapsinknowledge,policy,andaction,theLancetCommissiononGlobalSurgerywaslaunchedinJanuary,2014.TheCommissionbroughttogetheraninternational,multidisciplinaryteamof25commissioners,supported by advisors and collaborators in more than 110 countries andsixcontinents.

Weformedfourworkinggroupsthatfocusedonthedomainsofhealth-caredeliveryandmanagement; workforce,training,andeducation;economicsand finance;andinformationmanagement.OurCommissionhasfivekeymessages,asetofindicatorsand recommendationstoimproveaccesstosafe,affordablesurgicalandanaesthesiacareinLMICs,andatemplate foranationalsurgicalplan.Ourfivekeymessagesare presented as follows:

•5billionpeopledonothaveaccesstosafe,affordablesurgicalandanaesthesiacarewhenneeded.Accessisworstinlow-incomeandlower-middle-incomecountries,wherenineoftenpeoplecannotaccess basic surgical care.

•143millionadditionalsurgicalproceduresareneededinLMICseachyeartosavelivesandpreventdisability.Ofthe313millionproceduresundertakenworldwideeachyear,only6%occurinthepoorestcountries,whereoverathirdoftheworld’spopulationlives.Lowoperativevolumesareassociatedwithhighcase-fatalityratesfromcommon,treatablesurgicalconditions.Unmetneedisgreatestineastern,western,andcentralsub-Saharan Africa,andsouthAsia.

•33millionindividualsfacecatastrophichealth expenditureduetopaymentforsurgeryand anaesthesiacareeachyear.Anadditional48million casesofcatastrophicexpenditureareattributableto thenon-medicalcostsofaccessingsurgicalcare.A quarterofpeoplewhohaveasurgicalprocedurewill incur financial catastrophe as aresult of seeking care. Theburdenofcatastrophicexpenditureforsurgeryis highestinlow-incomeandlower-middle-incomecountriesand,withinanycountry,landsmostheavilyon poor people.

•InvestinginsurgicalservicesinLMICsisaffordable,saveslives,andpromoteseconomicgrowth.Tomeetpresentandprojectedpopulationdemands,urgentinvestmentinhumanandphysicalresourcesforsurgicalandanaesthesiacareisneeded.IfLMICsweretoscale-upsurgicalservicesatratesachievedbythepresentbest-performingLMICs,two-thirdsofcountrieswouldbeabletoreachaminimumoperativevolume of 5000 surgical procedures per100000populationby2030.Withouturgentandacceleratedinvestmentinsurgicalscale-up,LMICswillcontinuetohavelossesineconomicproductivity,estimatedcumulativelyatUS$12·3trillion(2010US$,purchasingpowerparity)between2015and2030.

•Surgeryisan“indivisible,indispensablepartofhealthcare.”1Surgicalandanaesthesiacareshouldbeanintegralcomponentofanationalhealthsystemin countriesatalllevelsofdevelopment.Surgicalservicesareaprerequisiteforthefullattainmentof localandglobalhealthgoalsinareasasdiverseas cancer,injury,cardiovasculardisease,infection,and reproductive, maternal, neonatal, and child health. Universalhealthcoverageandthe health aspirations setoutinthepost-2015SustainableDevelopment Goalswillbeimpossibletoachievewithoutensuring thatsurgicalandanaesthesiacareis available, accessible, safe, timely, and affordable.

Insummary,theCommission’skeyfindingsshowthatthehumanandeconomicconsequencesofuntreatedsurgicalconditionsinLMICsarelargeandformanyyears have gone unrecognised. During the pasttwodecades,globalhealthhasfocusedonindividualdiseases.Thedevelopmentofintegratedhealthservicesandhealthsystemshasbeensomewhatneglected.Assuch,surgicalcarehasbeenaffordedlowpriorityintheworld’spoorestregions.Ourreportpresentsaclearchallengetothisapproach.Asaneweraofglobalhealthbeginsin2015,thefocusshouldbeonthedevelopmentofbroad-basedhealth-systemssolutions,andresourcesshouldbeallocatedaccordingly.Surgicalcarehasanincontrovertible,cross-cuttingroleinachievementoflocalandglobalhealthchallenges.Itisanimportantpartofthesolutiontomanydiseases—forbotholdthreatsandnewchallenges—andacrucialcomponentofafunctional,responsive,andresilienthealthsystem.ThehealthgainsfromscalingupsurgicalcareinLMICsaregreatandtheeconomicbenefitssubstantial.Theyaccrueacrossalldisease-causecategoriesandatallstagesoflife,butespeciallybenefitouryouthandyoungadultpopulations.Theprovisionofsafeandaffordablesurgicalandanaesthesiacarewhenneedednotonlyreducesprematuredeathanddisability,butalsoboostswelfare,economicproductivity,capacity,andfreedoms,contributingtolong-term development. Our six core surgical indicators(table1)shouldbetrackedandreportedbyallcountriesandglobalhealthorganisations,suchastheWorldBankthroughtheWorldDevelopmentIndicators,WHOthroughtheGlobalReferenceListof100CoreHealthIndicators,andentitiestrackingtheSDGs.

AttheopeningmeetingoftheLancetCommissiononGlobalSurgeryinJanuary,2014,JimKim,PresidentoftheWorldBank,statedthat:“surgeryisanindivisible,indispensablepartofhealthcare”and“canhelpmillionsof people lead healthier, more productive lives”.1

In2015,goodreasonexiststoensurethataccessto surgical and anaesthesia care is realised for all.

References

1Kim, JY. Opening address to the inaugural “The Lancet Commissionon Global Surgery” meeting. The World Bank.Jan 17, 2014. Boston, MA, USA. (accessed March, 31, 2015).

Table 1 Core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care when needed

These indicators provide the most information when used and interpreted together; no single indicator provides an adequate representation of surgical and anaesthesia care when analysed independently

From: Meara JG, Leather AJ, Hagander L, Alkire B, Aloson N, Ameh E, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development: The Lancet Commissionon Global Surgery. The Lancet. 2015;April. With permission.

Published Online April 27, 2015 S0140-6736(15)60160-X

See Online/Comment S0140-6736(15)60465-2

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*Joint first authors

‡Prof Rodas died March 2, 2015; we dedicate our report to him

Program in Global Surgery and Social Change, Department of Global Health and Social Medicine (J G Meara MD, S L M Greenberg MD, N P Raykar MD, J N Riesel MD), and Department of Otology and Laryngology (M G Shrime MD), Harvard Medical School, Boston, USA; Boston Children’s Hospital, Boston, MA, USA (J G Meara, S L M Greenberg, N P Raykar, J N Riesel); King’s Centre for Global Health, King’s Health Partners and King’s College London, London, UK (A J M Leather MS, A J Dare PhD, C E Grimes MBBS); Pediatric Surgery and Global Pediatrics, Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden (L Hagander PhD); Department of Otolaryngology—Head and Neck Surgery (B C Alkire MD), and Office of Global Surgery (M G Shrime), Massachusetts Eye and Ear Infirmary, Boston, MA, USA; Plastic Surgery Department, University of São Paulo, São Paulo, Brazil (Prof N Alonso MD); Department of Surgery, Division of Peadiatric Surgery, National Hospital, Abuja, Nigeria (Prof E A Ameh MBBS); Rady Children’s Hospital, University of California, San Diego, San Diego, CA, USA (Prof S W Bickler MD); Department of Surgery, University of California, San Diego, CA, USA (J Rose MD); School of Public Health, Imperial College London, London, UK (L Conteh PhD); The Lancet, London, UK (J Davies MD); Department of Ministry of Health, Gressier, Ouest, Haiti (E DérivoisMérisier MD); Ministry of Health, Republic of Botswana (S El-Halabi MPH); Department of Global Health and Social Medicine, Division of Global Health Equity, Harvard Medical School and Brigham and Women’s Hospital, Boston, MA, USA (Prof P E Farmer PhD); Partners in Health, Boston, MA, USA (Prof P E Farmer); Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA (Prof A Gawande MD, J Rose); Ariadne Labs Boston, MA, USA (A Gawande); Royal North Shore Hospital, St Leonards, NSW, Australia (R Gillies MBBS); Medical College of Wisconsin, Milwaukee, WI, USA (S L M Greenberg); The Alfred Hospital and Monash University, Melbourne, VIC, Australia and Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (Prof R L Gruen PhD); Edna Adan University Hospital, Hargeisa, Somaliland (E Adan Ismail SCM); Connaught Hospital, Freetown, Sierra Leone (T Buya Kamara MBChB); Department of Surgery, University of Sierra Leone, Freetown, Sierra Leone (T Buya Kamara); Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK (Prof C Lavy FCS [ECSA]); Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia (Ganbold L PhD); Department of Surgery, College of Medicine, University of Malawi, Blantyre, Malawi (Prof N C MkandawireMCh(Orth); School of Medicine, Flinders University, Adelaide, SA, Australia (Prof N C Mkandawire); Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA (N P Raykar); Department of Surgery, Massachusetts General Hospital, Boston, MA, USA (J N Riesel); The Cinterandes Foundation, Universidad del Cuenca, and Universidad del Azuay, Cuenca, Ecuador (Prof E Rodas‡ MD); Universidad del Azuay, Cuenca, Ecuador (Prof E Rodas); BARC Hospital (Govt of India), Mumbai, India (N Roy MD); Harvard Interfaculty Initiative in Health Policy, Cambridge, MA, USA (M G Shrime); Institute of Cancer Policy, Kings Health Partners Integrated Cancer Centre, King’s Centre for Global Health, King’s College London, London, UK (Prof R Sullivan MD); Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA (S Verguet PhD); Royal Australasian College of Surgeons, East Melbourne, and DeakinUniversity,Melbourne, VIC, Australia (Prof D Watters ChM); Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA (T G Weiser MD); Department of Anaesthesia, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK (I H Wilson MBChB); Evidence to Policy Initiative, Global Health Group, University of California, San Francisco, CA, USA (G Yamey MD); and Blavatnik School of Government, University of Oxford, Oxford, UK (Prof W Yip PhD)

Correspondence to: Dr John G Meara, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School; and Boston Children’s Hospital, Boston, MA 02115, USA john.meara@childrens. harvard.edu

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LMICs

Although this term has been used throughout the report for brevity, the Commission realises that tremendous income diversity exists between and within this group of countries