International School of Surgery, ISS - Home
login | register
The International School of Surgery - ISS

Global Surgery Issues

The Lancet Commission has reported that billions of people lack access to basic surgical care, setting ambitious targets to deal with the problem. Will the world’s health leaders rise to the challenge?

The Lancet Commission on Global Surgery, which reported in April, demonstrated the immense disparity in the provision of surgical care across the globe. Surgery is an integral component of healthcare, yet access to surgical and anaesthetic care in low and middle-income countries (LMIC) is woefully poor. The commission, which was written by a group of 25 experts with contributions from more than 110 countries, was launched at a day-long symposium at the Royal Society of Medicine in London.

The report outlines that, of the 313 million operations done worldwide each year, just one in 20 occurs in the poorest countries, where more than one-third of the world’s population lives. New estimates produced for the Commission find that there is a global shortfall of at least 143 million surgical procedures every year, with some regions needing nearly twice as many additional operations as others.

The warning from the Commission could not be clearer, with Andy Leather, one of its lead authors and director of the King’s Centre for Global Health, saying, “The global community cannot continue to ignore this problem – millions of people are already dying unnecessarily, and the need for equitable and affordable access to surgical services is projected to increase in the coming decades, as many of the worst affected countries face rising rates of cancer, cardiovascular disease, and road accidents.”

The Commission’s key messages were that 5 billion people are unable to access safe surgery when needed and that the scaling up of surgical anaesthesia care is affordable, saves lives and promotes economic growth. It acknowledges that although the costs of delivering the additional procedures are large, the cost of doing nothing is greater still.

The report also linked access to surgery with affordability, and found that one-quarter of people worldwide who have a surgical procedure will incur financial catastrophe – costs that they can’t afford and which drive them into poverty – as a result of seeking care. The burden of catastrophic expenditure on surgery is highest in LMIC and, within any country, lands most heavily on poor people.

The publication of the Commission was quickly followed by official recognition by the World Health Assembly of the importance of access to surgery and anaesthesia as a component of universal health coverage.

Surgical colleges from around the world – including the RCSEd – joined forces to issue a statement of support. It read: “The Colleges undertake to promote research on access to safe, affordable and timely surgery, reporting on the WHO’s and the Lancet Commission’s recommended surgical indicators. We will progress these within our region and support low- and middle-income countries with whom we partner.”

The group pledged to report on progress as early as the October 2015 American College of Surgeons Congress with further updates at the May 2016 Royal Australasian College of Surgeons Congress.

“Access to safe surgical procedures is something that we take for granted in the UK and in many countries around the world, so it will be shocking to many that 5 billion of the global population do not have proper access to good surgical care,” said RCSEd president, Mr Ian Ritchie.

There are multiple factors that prevent access to surgery, including transport, surgical capacity, safety of surgery and ability to pay. The College believes that access to safe, affordable medical care should be the cornerstone of any health system but, despite massive leaps forward in global healthcare in the last 20 years, there has not been enough attention placed on the need for access to surgery.

Mr Ritchie expressed his hope that the Lancet Commission and new sustainable development goals can begin to tackle the inequality in healthcare that exists globally, commenting: “It is clear that we desperately need more surgical professionals if we are to meet the surgical needs of the world’s population. RCSEd is keen to be at the forefront of training and supporting surgeons as part of the global health workforce.”

The College has more than 7,000 Fellows and Members in around 100 countries and, in 2012, established the RCSEd International School of Surgery (ISS), which offers educational support for surgeons and surgical professionals throughout their careers. The ISS provides access to courses, training and examinations globally, helping improve standards and set a benchmark for surgical excellence. This includes the College’s Basic Surgical Skills (BSS) course, which gives surgical trainees exposure to the skills they need to deliver surgical care.

Ultimately, the College’s aim is to help develop surgical capacity in countries where it is needed, promoting the continuity and dissemination of skills, all of which support the aims of the Lancet Commission. A recent example is an initiative to work with urological surgeons in Myanmar and build an improved surgical curriculum that will support and develop surgical capacity in the country.

So what has been the reaction from the wider surgical community and those who have experience of working within healthcare systems in LMIC?

“The road to improving access is difficult but not impossible, as the Commission clearly shows,” says Dr Paul McMaster, of Médecins Sans Frontières. But, as McMaster points out, part of the challenge is the complex nature of diseases and conditions that require basic surgical care: “If it was a single treatable disease wreaking havoc, the world would be much more likely to act. But because the surgical burden of disease is less easy to ‘package’ as a problem, the suffering will continue, unless we heed and adopt the approach advocated by the Lancet Commission.”

Professor A R Sharfi, a member of the College’s International Surgical Adviser (ISA) network and head of the Department of Surgery, University of Khartoum, Sudan, gives an example of the multi-faceted challenges of providing surgical care: “As is the case in many African countries, complications from a variety of factors are an all too regular feature of surgery in North Sudan.” Professor Sharfi says one of the main reasons for this problem is that many patients present with advanced disease because they have been treated at an earlier stage by ‘native healers’ (non-medically qualified practitioners of herbal and other types of medicine).

“This puts an extra burden on medical professionals,” continues Professor Sharfi. “Besides treating patients, they must play a major part in educating patients through primary healthcare centres and the media. Therefore, I hope that one of the benefits of the Lancet Commission on Global Surgery will be to help reduce complications, and therefore the higher costs, of surgical treatment in many African countries.”

A further complication is the fact that levels of access to surgery can vary considerably within single countries, as Dr P Raghu Ram, ISA in India and Padma Shri Awardee for 2015, explains: “To say there is huge variation in the surgical care across India would be an understatement. While there are a few centres in the country that offer surgical care on a par with the best in the world, delivery of surgical care and, for that matter healthcare in India, is a lottery, with some getting excellent care and most not.”

Dr Raghu believes there is inadequate priority given to public health, with current spending on healthcare in India sitting at around 1% (which is low even compared with many ‘developing’ nations).

The Lancet Commission has succeeded in pulling together the strands of a disparate and complex global problem. The challenge now facing the worldwide surgical community is to combine expertise, influence and resources to help the 5 billion who do not have access to surgery.


SN Sept15This article is from the September 2015 edition of Surgeons' News, membership magazine of the Royal College of Surgeons of Edinburgh


More information on RCSEd projects to build surgical capacity around the world

Upcoming System Maintenance & Network Disruption

Due to essential systems maintenance and upgrades there will be intermittent interruptions to some on-line services on Saturday 27th of February. There will be further interruption to some core services on Wednesday 2nd and Thursday 3rd of March.

We apologise for any inconvenience caused.