Key Findings & Recommendations from:
Global Surgery 2030: Evidence and Solutions for
Achieving Health, Welfare and Economic Development
1
Healthcare Delivery and Management
Panel 2 Healthcare delivery and management key findings

Patients face significant barriers in accessing surgical care, inhibited by financial, geographic, and
cultural issues; and poor pre-hospital transportation systems

Poor connectivity between traditional healthcare providers, community health workers, and the
formal health system compromises surgical care delivery

Most hospitals lack the necessities for surgical care provision including basic physical
infrastructure, equipment, supplies and support services such as radiology, pathology and
equipment maintenance

Limited focus on leadership, management, and research leads to process inefficiencies, poor
system performance and suboptimal safety

International assistance in the form of equipment donations and visiting surgical teams is often not
designed to contribute towards long-lasting system improvement

Performance of the Bellwether Procedures (laparotomy, caesarean delivery and open fracture
fixation) serves as a proxy indicator for delivery of a broad range of surgical care; 80-90% of
which can be provided in well-equipped first-level hospitals
2
RECOMMENDATIONS
National (Hospitals, Ministries of Health)

Outreach efforts that are culturally and contextually appropriate should be developed to
promote health system usage amongst the community and alternative providers

Comprehensive low-cost pre-hospital referral systems can be developed leveraging
community health workers and mobile connectivity

All first-level hospitals should aim to provide the Bellwether Procedures (defined by the
Commission as laparotomy, caesarean delivery, and treatment of open fracture) because
these are acute, high-value procedures and because their consistent provision requires
functional surgical systems capable of a wide range of care delivery

Professional healthcare managers, both clinicians or non-clinicians with management
training, should be trained and empowered to improve access, efficiency, performance, safety
and to coordinate system-wide care delivery

Tertiary hospitals must play a key role as the system’s education, clinical support and
research hub

A national blood donation strategy must be developed to assure blood donations of at least 15
donations/1 000 and ensure equitable distribution of blood bank infrastructure

Centralized framework purchasing agreements with decentralized ordering and strong supply
chain management should be utilized to allow hospital facilities to order per local needs
International (WHO, NGOs, Professional Societies, Industry)

Clinical guidelines and protocols relevant to the low-resource setting should be established
and placed on-line by the WHO

All donated equipment should be accompanied by long-term maintenance contracts or should
be replaced with funds for other local investments

International professional societies, high income academic medical centers and NGOs play
an important role in coordinating short-term interventions and support; this should be within
3
the framework of long-term commitments focused on system strengthening and should be
demand driven

International consortiums consisting of public and private partnerships can make a powerful
impact in driving forward innovation and scale-up in the areas of medical devices,
biomedical equipment training, and mobile-Health applications
4
Workforce, Training, and Education
Panel 3 Workforce, training and education key findings

The surgical workforce is a diverse network of individuals who collectively contribute to the delivery of
surgical and anaesthesia care

There are over 2 million specialist surgeons, anaesthesiologists, and obstetricians in the world but their
distribution is not commensurate with population size and need; the poorest half of the global population is
served by only a fifth of the global specialist surgical workforce

To meet projected population needs by 2030, today’s surgical workforce would need to double in 15 years.
Task sharing in combination with scale-up of specialist surgical and anaesthetic providers may be an
appropriate means of achieving workforce goals

Accreditation, licensing, and continuing professional development, shown to improve quality of the provision of
care, are poorly documented around the world

Rural surgical and anaesthesia care is underemphasized in graduate and post-graduate surgical and anaesthetic
education contributing to the mal-distribution of surgical and anaesthetic providers worldwide
5
RECOMMENDATIONS
National

Ministries of Health should record the density and distribution of all surgical and
anaesthetic providers including surgical and anaesthetic specialist providers, general
practitioners, and associate clinicians

Ministries of Health should develop surgical workforce plans to achieve surgical
workforce densities of 20-40/100 000 with adequate rural and urban distribution by 2030
as an interim goal; this goal can be re-set then based on local evidence and community
needs

All surgical workforce training programs should have a required rural training component
that is sufficiently mentored and supervised

All graduate and post graduate training programs should be accredited

All actively practicing providers must be licensed and relicensed through available and
affordable competency-based examinations and Continuing Professional Development
(CPD)

Access to reliable internet, information, and mentoring is required at all training sites and
first level hospitals
International
•
Ministries of Health, Finance, and Education and Regional Professional Bodies should
collaborate to support regional training and education opportunities.
International Funding Agents:

In low-income countries, multi-year funding should be directed toward large scale health
system strengthening programs that include education of the entire surgical workforce

In middle-income countries, funding should be directed toward rural service incentives to
improve surgical workforce distribution
6
WHO
Partner with Ministries of Health to record and publish surgical workforce density and
distribution in all UN-member countries annually.
NGOS, Professional Organizations, HIC Academic Institutions
Work in partnership with local institutions to improve surgical capacity through longitudinal
educational programs that do not drain human resources away from the public system
7
Economics and Financing
Panel 4 Economics and financing key findings

There is a strong case for investing in surgical and anaesthesia care within health systems in LMICs

The macroeconomic impact of surgical conditions in LMICs is substantial, and will rise considerably between
2015-2030 without significant and early investment in surgical capacity building

Basic, life-saving surgical and anaesthesia care, delivered at the first level hospital, can be very cost-effective in
LMICs

User fees at the point of care remain a predominant financing mechanism for surgical and anaesthesia care in
many LMICs: this can be impoverishing, and negatively affects equity and access to surgical and anaesthesia
care

Catastrophic health expenditure from the direct medical and non-medical costs of surgery affects a quarter of all
those accessing surgical and anaesthesia care globally, and has the greatest impact on the poorest in all
countries.

Tracking financial flows to surgery through domestic accounts and international development assistance is
currently not possible

From the financial data that is available, domestic and international contributions to surgical and anaesthesia
care are small and are not always well aligned with surgical needs in LMICs
8
RECOMMENDATIONS
National (Govt/MOH/MOF)

UHC policies must include surgery and cover basic packages of surgical and
anaesthesia care from early within the expansion pathway

Health financing mechanisms for surgical and anaesthesia care that are based on riskpooling should be used instead of user fees at the point of care.

Risk pooling using a single pool and payer (e.g. a public national health
insurance) can improve equity, access and financial risk protection

Increased mobilisation of domestic health financing sources towards surgical and
anaesthesia care is required to meet the costs of scaling up surgical and anaesthesia
services to a minimally acceptable level

Early investments will pay the greatest dividends in terms of health
benefits and economic and welfare gains

Better tracking of financing flows to surgical services through National Health
Accounts is needed.


Disaggregated accounting and improved transparency will assist with this.
Strategic purchasing: risk pooled funds for surgical services that pay providers based
on quality output and outcomes should be further explored as a means of improving
quality and efficiency,
International (WB/WHO/USAID/OECD/Eurostat)

Surgical and anaesthesia care must be included within UHC policies and goals

Increased international health financing (e.g. traditional DAH, innovative global health
financing) is needed to finance the scale-up of surgical services in many LMICs,
particularly for capital costs.

Financing of health systems strengthening in LMICs must explicitly include
surgical services

Tracking financing flows to surgery within global DAH/ODA databases is required

Greater transparency and disaggregation of spending within DAH accounts will
assist with tracking efforts
9

The international System of Health Accounts* frameworks should include and collect
surgical data to allow for standardised reporting of expenditure on surgical and
anaesthesia care and its financing, in order to facilitate international comparisons.

Surgical and anaesthesia care should be included within the International
Classification of Health Accounts Health Care, Health Providers and Health
Financing tables

Greater attention should be given to the use of innovation and technology to reduce costs
and optimise the use of resources in the delivery of surgical and anaesthesia care in lowresource environments
*The System of Health Accounts outlines statistical reporting rules for financial date provided by National Health
Accounts. It allows for international comparisons of health care spending between countries with different ways of
organising healthcare and its financing.
10
Information Management
Panel 5 Information management key findings

Comprehensive surgical and anaesthesia data is absent from major global health databases and repositories,
compromising process improvement and research

Validated and uniformly used methods to assess the burden of surgical conditions are lacking

Monitoring surgical services requires attention to the ‘preparedness’ for surgical and anaesthesia care, the
‘delivery’ of surgical and anaesthesia care, and the ‘impact’ of surgical and anaesthesia care

No standard indicators of surgical and anaesthesia care delivery have been adopted globally. Caesarean delivery
rate is the only surgically relevant indicator commonly used by major international agencies.

There is no standardized, accepted and utilized coding system for surgical conditions or procedures; this limits
the ability to track clinical throughput as well as financial flows linked to surgical and anaesthesia care
11
Table 3 Core indicators for monitoring realization of universal access to safe, affordable surgical and anaesthesia care when needed
Indicator
Definition
Rationale
Data Sources
Responsible
Entity
Comments
Target
Informs policy and
planning regarding
location of services in
relation to population
density, transport
systems and facility
service delivery
Informs workforce,
training and retention
strategies
A minimum of 80% coverage
of essential surgical and
anaesthesia services per
country by 2030
Group 1: Preparedness for surgical and anaesthesia care
Access to timely
essential surgery
Percent of the population that can
access, within 2 hours, a facility
that can perform emergency
caesarean section, laparotomy and
open fracture fixation (the
Bellwether procedures)
All people should have timely access to
emergency surgical services. Bellwether
procedure performance predicts performance
of many other essential surgical procedures.
Two hours is a threshold of death from
complications of childbirth.
Facility records
and population
demographics
MoH
Specialist surgical
workforce density
Number of specialist surgical,
anaesthetic and obstetric
physicians who are working, per
100 000 population
The availability and accessibility of human
resources for health is a crucial component of
surgical and anaesthesia care delivery
Facility records,
data from
training and
licensing bodies
MoH
100% of countries with at least
20 SAO/100 000 population by
2030
Group 2: Delivery of surgical and anaesthesia care
Surgical volume
Procedures performed in an
operating theatre, per 100 000
population, per year
The number of surgical procedures performed
per year is an indicator of met need
Facility records
Facility
MoH
Informs policy and
planning regarding met
and unmet need for
surgical care
1. 80% of countries by 2020
and 100% of countries by 2030
tracking surgical volume
2. 5 000 procedures per
100 000 population by 2030
Perioperative
mortality rate
(POMR)
All cause death rate prior to
discharge among patients who
have undergone a procedure in an
operating theatre, divided by the
total number of procedures,
presented as a percentage
Surgical and anaesthesia safety is an integral
component of care delivery. POMR
encompasses deaths in the operating theatre
and in the hospital post-procedure.
Facility records
and death
registries
Facility
MoH
Informs policy and
planning regarding
surgical and anaesthesia
safety, as well as
surgical volume when
number of operations is
the denominator
1. 80% of countries by 2020
and 100% of countries by 2030
tracking POMR
2. In 2020 evaluate global data
and set national targets for
2030
Group 3: Impact of surgical and anaesthesia care
Protection against
impoverishing
expenditure
Fraction of households protected
against impoverishment** from
direct OOP payments for surgical
and anaesthesia care
Billions of people are at risk of financial ruin
from accessing surgical services each year.
This is a surgery specific version of a WB
UHC target.
Household
surveys, facility
records
WB
WHO
USAID
Informs policy about
payment systems,
insurance coverage, and
balance of public and
private services
100% protection against
impoverishment from OOP
payments for surgical and
anaesthesia care by 2030
Protection against
catastrophic
expenditure
Fraction of households protected
against catastrophic
expenditure*** from direct OOP
payments for surgical and
anaesthesia care
Billions of people are at risk of financial ruin
from accessing surgical services each year.
This is a surgery specific version of a WB
UHC target.
Household
surveys, facility
records
WB
WHO
USAID
Informs policy about
payment systems,
insurance coverage, and
balance of public and
private services
100% protection against
catastrophic expenditure from
OOP payments for surgical and
anaesthesia care by 2030
*Equity stratifiers listed in discussion
**Impoverishing expenditure defined as (1) being pushed into poverty or (2) being pushed further into poverty by OOP payments43
*** Catastrophic expenditure is defined as direct OOP payments of greater than 40% of household income net of subsistence needs105
****Access, workforce, volume and POMR indicators should be reported annually. Financial protection indicators should be reported alongside the WB/WHO measures of financial protection for UHC.
12
RECOMMENDATIONS
National:

National systems of disease monitoring (whether through CRVS, household surveys, DSS or
VA) should capture morbidity and mortality from essential surgical conditions, including
injuries and burns, digestive diseases, malignancies, wounds, maternal and neonatal
conditions, and congenital anomalies.

More research should be undertaken to identify accurate and feasible methods of determining
prevalence of surgical disease in the population

Uniformly collected core surgical indicators - including access to timely essential surgery,
specialist surgical workforce density, surgical volume, POMR, protection against
impoverishing expenditure and catastrophic expenditure – should be used by countries to
assess preparedness, delivery and impact of surgical and anaesthesia care

To allow tracking of our six core indicators, all facilities and groups delivering surgical and
anaesthesia care should collect a minimum surgical dataset and submit that information to
their Ministries of Health or National Statistical Bodies

Core surgical indicators should be analyzed at the national level, used to institute necessary
changes, and distributed to the WHO and World Bank for global reporting

A uniform method for coding surgical conditions and operations should be agreed upon and
used globally to facilitate data analysis and comparison, and that enables the burden of
surgical disease as well as the unmet and met needs to be reported

Facilities and countries should work to strengthen their information systems to allow
collection of additional disaggregated information to further inform the six core indicators
13
International:

All population-based disease monitoring mechanisms, including household surveys, should
capture morbidity and mortality from essential surgical conditions, including injuries and
burns, digestive diseases, malignancies, wounds, maternal and neonatal conditions, and
congenital anomalies

A uniform method for coding medical and surgical conditions and operations should be
adopted and promoted for use

A single facility-based survey should be adopted by the World Health Organization and
utilized by countries to facilitate comparable assessment of facility availability and readiness
to delivery surgical care

Our six core surgical indicators - access to timely essential surgery, specialist surgical
workforce density, surgical volume, POMR, protection against impoverishing expenditure
and catastrophic expenditure – should be tracked and reported by global health organizations,
such as the World Bank through the World Development Indicators, and the WHO through
the Global Reference List of 100 Core Health Indicators
14
Research
Panel 6 Research key findings

The majority of surgical research is done in high-income countries by high-income researchers; surgical
research output correlates with country GDP

There are large knowledge gaps across nearly all global surgery research topics

Current surgical research capacity in LMICs is weak with a lack of training, funding and prioritization

Research needs vary by environment, highlighting the need for locally-driven research agendas
RECOMMENDATIONS
National and International:

Increasing research capacity, training, funding and output in LMICs should be a priority on
both local and global levels

Local research capacity should be facilitated with international funding and capacity-building
partnerships, and driven by local priorities

In addition to further defining the problem, global surgery research focus should also extend
to identifying solutions – particularly in the areas of financing, quality, safety, care delivery
innovations and clinical effectiveness

Funders, editors and ethical committees should consider a list of core questions, such as those
identified by the Commission, when reviewing global surgery research projects
15
Section 7: National Surgical Plan
16
Table 4 Framework for a national surgical plan
Infrastructure
Components
- Surgical facilities
- Facility readiness
- Blood supply
- Access and referral
systems
Workforce
Components
- Surgical, anaesthetic and
obstetric providers
- Allied health providers
(nursing; operational
managers; biomedical
engineers; radiology,
pathology and laboratory
technician officers)
Service Delivery
Components
- Surgical volume
- System coordination
- Quality and safety
Financing
Components
- Health financing and
accounting
- Budget allocation
Information Management
Component
- Information systems
- Research agenda
17
Recommendations
- Track number and distribution of surgical facilities
- Negotiate centralized framework purchase agreements with decentralized ordering
- Equip first-level surgical facilities to be able to perform laparotomy, caesarean delivery
and open fracture fixation (the Bellwether Procedures)
- Develop national blood plan
- Reduce barriers to access through enhanced connectivity across entire care delivery chain
from community to tertiary care
- Establish referral systems with community integration, transfer criteria, referral logistics,
protections for first-responders and Good Samaritans
Assessment Tools and Evaluation
- Proportion of population with 2-hour access to first-level facility
- WHO SARA and/or Hospital Assessment Tool (i.e. evaluation of
structure, electricity, water, oxygen, surgical equipment and supplies,
computers and internet, etc.)
- Proportion of hospitals fulfilling safe surgery criteria
- Blood bank distribution, donation rate
Recommendations
- Establish training and education strategy based on population and needs of country
- Require rural component of surgical and anaesthetic training programs
- Develop a context-appropriate licensing and credentialing requirement for all surgical
workforce
- Training and education strategy of ancillary staff based on population and needs of
country
-Invest in professional healthcare manager training
- Establish biomedical equipment training program
- ms
Assessment Tools and Evaluation
- Density and distribution of specialist surgical, anaesthetic, and obstetric
providers
- Number of surgical, anaesthetic and obstetric graduates and retirees
- Proportion of surgical workforce training programs accredited
- Presence of task sharing or nursing accredited programs and number of
providers
- Presence of attraction and retention strategies
- Density and distribution of nurses, ancillary staff including operational
managers, biomedical engineers, radiology, pathology and laboratory
technicians
Recommendations
- All first-level hospitals should provide laparotomy, caesarean delivery and open fracture
fixation (the Bellwether Procedures)
- Integrate public, private, NGO providers into common national delivery framework;
promote demand-driven partnerships with NGOs to build surgical capacity
- Prioritize healthcare management training
- Prioritize quality improvement processes and outcomes monitoring
- Promote telemedicine to build system-wide connectivity
- Promote system-wide connectivity for telemedicine applications, clinical support and
education
Assessment Tools and Evaluation
- Proportion of surgical facilities offering the Bellwether Procedures
- Surgical procedures performed per year
- Surgical and anaesthetic related morbidity and mortality (POMR)
- Availability of system wide communication
Recommendations
- Cover basic surgical packages within UHC
- Risk pool using a single pool and payer; minimize user fees at the point of care
- Track financial flows for surgery through National Health Accounts
- Employ value-based purchasing with risk pooled funds
Assessment Tools and Evaluation
- Surgical expenditure as a proportion of GDP
- Surgical expenditure as a proportion of total national health care budget
- Out of pocket expenditures on surgery
- Catastrophic and impoverishing expenditures on surgery
Recommendations
- Develop robust information systems to monitor clinical processes, cost, outcomes and
identify deficits
- Identify, regulate, fund surgical research priorities of local relevance
Assessment Tools and Evaluations
- Presence of data systems that promote monitoring & accountability
related to surgical and anaesthesia care
- Proportion of hospital facilities with high speed internet connections
18