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Debas HT, Donkor P, Gawande A, et al., editors. Essential Surgery: Disease Control Priorities, Third Edition (Volume 1). Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2015 Apr 2. doi: 10.1596/978-1-4648-0346-8_ch1

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Essential Surgery: Disease Control Priorities, Third Edition (Volume 1).

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Chapter 1Essential Surgery: Key Messages of This Volume

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Volume Summary

Essential Surgery reflects an increased emphasis on health systems relative to previous editions of Disease Control Priorities. This volume identifies 44 surgical procedures as essential on the basis that they address substantial needs, are cost-effective, and can feasibly be implemented. This chapter summarizes and critically assesses the volume’s key findings:

  • Provision of essential surgical procedures would avert an estimated 1.5 million deaths a year, or 6 percent to 7 percent of all avertable deaths in low- and middle-income countries (LMICs).
  • Essential surgical procedures rank among the most cost-effective of all health interventions. The surgical platform of first-level hospitals delivers 28 of the 44 essential procedures, making investment in this platform also highly cost-effective.
  • Measures to expand access to surgery, such as task-sharing, have been shown to be safe and effective while countries make long-term investments in building surgical and anesthesia workforces. Because emergency procedures constitute 23 of the 28 procedures provided at first-level hospitals, such facilities must be widely geographically available.
  • Substantial disparities remain in the safety of surgical care, driven by high perioperative mortality rates and anesthesia-related deaths in LMICs. Feasible measures, such as the World Health Organization’s (WHO’s) Surgical Safety Checklist (WHO 2008a), have led to improvements in safety and quality.
  • The large burden of surgical conditions, the cost-effectiveness of essential surgery, and the strong public demand for surgical services suggest that universal coverage of essential surgery (UCES) should be financed early on the path to universal health coverage. We point to estimates that full coverage of the component of UCES applicable to first-level hospitals would require slightly more than $3 billion annually of additional spending and yield a benefit:cost ratio of better than 10:1. It would efficiently and equitably provide health benefits and financial protection, and it would contribute to stronger health systems.


Conditions that are treated primarily or frequently by surgery constitute a significant portion of the global burden of disease. In 2011, injuries killed nearly 5 million people; 270,000 women died from complications of pregnancy (WHO 2014). Many of these injury- and obstetric-related deaths, as well as deaths from other causes such as abdominal emergencies and congenital anomalies, could be prevented by improved access to surgical care.

Despite this substantial burden, surgical services are not being delivered to many of those who need them most. An estimated 2 billion people lack access to even the most basic surgical care (Funk and others 2010). This need has not been widely acknowledged, and priorities for investing in health systems’ surgical capacities have only recently been investigated. Indeed, until the 1990s, health policy in resource-constrained settings focused sharply on infectious diseases and undernutrition, especially in children. Surgical capacity was developing in urban areas but was often viewed as a secondary priority that principally served those who were better off.

In the 1990s, a number of studies began to question the perception that surgery was costly and low in effectiveness. Economic evaluations of cataract surgery found the procedure to be cost-effective, even under resource-constrained circumstances; Javitt pioneered cost-effectiveness analysis (CEA) for surgery, including his chapter on cataract in Disease Control Priorities, first edition (DCP1) in 1993 (Javitt 1993). In 2003, McCord and Chowdhury enriched the approach to economic evaluation in surgery in a paper looking at the overall cost-effectiveness of a surgical platform in Bangladesh (McCord and Chowdhury 2003). By design, DCP2, published in 2006, placed much more emphasis on surgery than had previous health policy documents. DCP2 included a dedicated chapter on surgery that amplified the approach of McCord and Chowdhury and provided an initial estimate of the amount of disease burden that could be addressed by surgical intervention in LMICs (Debas and others 2006). DCP3 places still greater emphasis on surgery by dedicating this entire volume (out of a total of nine volumes) to the topic. There is also a growing academic literature on surgery’s importance in health system development; for example, Paul Farmer and Jim Kim’s paper observes that “surgery may be thought of as the neglected stepchild of global public health” (Farmer and Kim 2008, 533). The WHO is paying increasing attention to surgical care through such vehicles as its Global Initiative for Emergency and Essential Surgical Care. Finally, the creation of The Lancet Commission on Global Surgery, now well into its work, points to a major change in the perceived importance of surgery.

The chapter seeks to do the following:

  • Better define the health burden of conditions requiring surgery
  • Identify those surgical procedures that are the most cost-effective and cost-beneficial
  • Describe the health care policies and platforms that can universally deliver these procedures at high quality. In particular, Essential Surgery seeks to define and study a package of essential surgical procedures that would lead to significant improvements in health if they were universally delivered. This chapter and the volume focus on the situation of low-income countries (LICs) and lower-middle-income countries.

Box 1.1 describes the history, objectives, and contents of DCP3 (Jamison 2015).

Box Icon

Box 1.1

From the Series Editors of Disease Control Priorities, Third Edition. Budgets constrain choices. Policy analysis helps decision makers achieve the greatest value from limited available resources. In 1993, the World Bank published Disease Control Priorities (more...)


Health conditions cannot be neatly split between conditions that require surgery and those that do not. Different diagnoses range widely in the proportion of patients requiring some type of surgical procedure. At the upper end are admissions for musculoskeletal conditions; 84 percent of these patients underwent some type of surgical procedure in an operating room in the United States in 2010. At the lower end are admissions for mental health conditions (0.4 percent) (Rose and others 2014).

The surgical capabilities required are not only those related to performing operations. Surgical care also involves preoperative assessment, including the decision to operate; provision of safe anesthesia; and postoperative care. Even when patients do not need surgical procedures, surgical providers often provide care, such as management of severe head injuries and resuscitation for airway compromise and shock in patients with trauma. Such care occurs in contexts in which clinicians must be prepared to intervene operatively as complications arise or conditions deteriorate.

Within the limitations inherent in defining surgical conditions, DCP3 has outlined, by consensus, a group of essential surgical conditions and the procedures and other surgical care needed to treat them. Essential surgical conditions can be defined as those that meet the following criteria:

In most situations, procedures to treat these conditions, for example, cesarean section, can be done at first-level hospital—those that have 50–200 beds, serve 50,000–200,000 people, and have basic surgical capabilities. However, treatments for some conditions, for example, cataract extraction, are primarily provided at higher level or specialized facilities. Table 1.1 lists the procedures that we define to be essential; this chapter addresses those conditions listed. We acknowledge that the list is not exhaustive, and other procedures might be considered as essential. For many countries, though, table 1.1 will provide a reasonable starting point for an essential surgical package, although there will be country-specific variations. Safe anesthesia and perioperative care are necessary components of all of these procedures.

Table 1.1. The Essential Surgery Package: Procedures and Platforms,.

Table 1.1

The Essential Surgery Package: Procedures and Platforms,.

Key Messages

This chapter synthesizes the main results of the individual chapters of Essential Surgery to provide broad directions for policy. The key messages deriving from our analysis are summarized and explained in the following sections and concern five categories of results: the surgically avertable disease burden, cost-effectiveness and economics, improving access, improving quality, and essential surgery in the context of universal health coverage (UHC).

Disease Burden Avertable by Essential Surgery

The conditions treated at least in part by the procedures in table 1.1 account for 4.7 million deaths (nearly 10 percent of all deaths) in LMICs (table 1.2). This figure is likely to be an underestimate; the burden of several common surgical conditions listed in table 1.1, for example, bowel obstruction or gallbladder disease, are not estimated as distinct entities in the WHO Global Health Estimates and hence not included in table 1.2. With UCES in LMICs, 1.5 million deaths per year could be averted (table 1.3), representing 6.5 percent of all avertable deaths in LMICs.

Table 1.2. Total Burden of Conditions Addressed by Essential Surgery, Low- and-Middle-Income Countries, 2011.

Table 1.2

Total Burden of Conditions Addressed by Essential Surgery, Low- and-Middle-Income Countries, 2011.

Table 1.3. Disease Burden Avertable by Essential Surgery, Low- and Middle-Income Countries, 2011.

Table 1.3

Disease Burden Avertable by Essential Surgery, Low- and Middle-Income Countries, 2011.

In comparison, DCP2 estimated that 11 percent of the total global burden of death and disability was from conditions that were very likely to require surgery (Debas and others 2006; Laxminarayan and others 2006). The current estimates are based on a more rigorous estimation method and a more narrowly defined subset of essential surgical conditions (figure 1.1) that excludes other highly prevalent conditions often treated by surgery, such as cancer and vascular disease.

Figure 1.1. Deaths, Avertable Deaths, and Surgically Avertable Deaths in Low- and Middle-Income Countries, 2011.

Figure 1.1

Deaths, Avertable Deaths, and Surgically Avertable Deaths in Low- and Middle-Income Countries, 2011.

Obtaining more accurate estimates of the avertable burden from surgically treatable conditions will require broad agreement on a definition of the concept of avertable burden and the methods for its measurement. The steps taken in Essential Surgery should be regarded as preliminary. Better estimates of the avertable burden will require more systematic data gathering from hospitals and population-based surveys on the significant proportion of the world’s people who lack access to surgical care. Such a survey recently conducted in Sierra Leone indicated that 25 percent of deaths might have been prevented with timely surgical care (Groen and others 2012). Similar studies need to be repeated more widely. In addition to individual research studies, the international community could contribute to developing and promoting metrics for ongoing monitoring of the burden of essential surgical conditions, as is currently done for maternal mortality.

Economic Evaluation of Essential Surgery

Surgical Procedures. At the time of DCP2, a small number of cost-effectiveness analyses had found specific surgical procedures to be very cost-effective. Since then, the literature has expanded and consistently documented that many of the essential surgical services identified in this chapter rank among health care’s most cost-effective interventions (figure 1.2). A few examples, all context-specific, include cleft lip repair (US$10–US$110 per disability adjusted life year [DALY] averted), inguinal hernia repair (US$10–US$100 per DALY averted), cataract surgery (US$50 per DALY averted), and emergency cesarean section (US$15–US$380 per DALY averted). Many of the widely disseminated public health measures are of similar cost-effectiveness or are not as cost-effective: of vitamin A supplementation (US$10 per DALY averted), oral rehydration solution (more than US$1,000 per DALY averted), and antiretroviral therapy for HIV/AIDS (US$900 per DALY averted) (Chao and others 2014; Grimes and others 2014).

Figure 1.2. Cost-Effectiveness of Surgical Interventions.

Figure 1.2

Cost-Effectiveness of Surgical Interventions.

Benefit-cost analyses have shown similar findings. An analysis of the benefits from cleft lip repair looked at the costs needed to run a specialized cleft clinic in India and the resulting health benefits, to which a monetary benefit was ascribed. Cleft surgery had a cost of approximately US$300 per DALY averted and a benefit-cost ratio (BCR) of 12 (Alkire, Vincent, and Meara 2015). These findings put cleft repair within the BCR range for the key investment priorities for disease control established by the Copenhagen Consensus, an organization that asks experts to rank global health and development interventions (Jamison, Jha, and others 2013). The BCR for cleft surgery is also very high in the range of BCRs across different development sectors. Box 1.2 provides an overview of approaches to economic evaluation of surgical procedures and an overview of findings.

Box Icon

Box 1.2

Economic Evaluation of Investments in Surgery. Economic evaluations aim to inform decision making by quantifying the tradeoffs between resource inputs required for alternative investments and resulting outcomes. Four approaches to economic evaluation (more...)

Surgical Platforms. The cost-effectiveness of certain platforms or facility types for providing surgical care also needs to be considered. Essential Surgery includes a chapter on CEA (Prinja and others 2015). Basic essential procedures are likely to be cost-effective when delivered at any level of the health care system. However, the first-level hospital has been found to be especially cost-effective as a surgical delivery platform, with costs of US$10–US$220 per DALY averted for all surgical care delivered, across a wide range of LMICs (Gosselin and Heitto 2008; Gosselin, Maldonado, and Elder 2010; Gosselin, Thind, and Bellardinelli 2006; McCord and Chowdhury 2003). Most surgery in first-level hospitals is emergency surgery. Therefore, health systems need to disperse surgical facilities widely in the population, and surgical teams working in first-level hospital should have a broad array of basic emergency skills rather than a narrow range of specialized skills.

Our analysis also considered a range of other surgical platforms. Short-term surgical missions by outside surgeons appear beneficial only if no other option is available; otherwise, suboptimal outcomes, unfavorable cost-effectiveness, and lack of sustainability limit their usefulness. Self-contained mobile platforms, such as hospital ships, appear to offer good outcomes for people who can reach them, but there are no data on their cost-effectiveness and obvious limitations for scale-up and national ownership. Specialized hospitals, including those providing surgery for cataract and obstetric fistula, appear to be among the most cost-effective of the competing options for specialized platforms (Shrime, Sleemi, and Ravilla 2015). Such specialized hospitals would be most sustainable if they develop strong links with local practitioners living and working in that country to promote training and to ensure appropriate postsurgical care, and if they eventually evolve to be led by these local professionals. Since most essential procedures undertaken in specialized hospitals are elective rather than urgent, patients can be scheduled to achieve high volumes, contain costs, and improve technical quality.

Many people with surgical conditions, especially trauma, die in prehospital settings. For example, one study found that 81 percent of trauma deaths were in prehospital settings in Kumasi, Ghana (Mock and others 1998). Most prehospital deaths occur in areas of LMICs where formal emergency medical services are rudimentary or absent. Improving the first aid skills of lay first responders can cost less than US$10 per year of life gained, making it one of the most cost-effective of all health interventions. Similarly, basic ambulance services can cost less than US$300 per year of life gained, which is still highly cost-effective (Thind and others 2015).

Cost of Universal Access. Jamison and colleagues estimate that it would cost approximately US$3 billion annually to scale up delivery of the component of the essential surgery package shown in table 1.1 that is applicable to first-level hospitals, so that this package would be available universally (Jamison, Jha, and others 2013). This expenditure would have a BCR of 10:1, which is broadly consistent with the BCR of other surgical procedures as described by Alkire, Vincent, and Meara (2015).

Improving Access

Challenges. The significant avertable burden from surgical conditions is directly related to the low capacity for surgical care in many LMICs, as reflected in the numbers of surgical procedures performed globally (map 1.1). Most operations (60 percent) take place in wealthier countries where 15 percent of the world’s people live. Only 3.5 percent of operations take place in the poorer countries where 35 percent of the world’s people live (Weiser and others 2008).

Map 1.1. Number of Surgical Procedures per 100,000 Population, 2004.

Map 1.1

Number of Surgical Procedures per 100,000 Population, 2004.

Across 23 LMICs, the ratio of general surgeons per population ranges from 0.13 to 1.57 per 100,000; the ratio of anesthesiologists per population ranges from 0 to 4.9 per 100,000 (Hoyler and others 2014). In contrast, the United States has 9 general surgeons and 11.4 anesthesiologists per 100,000 (Stewart and others 2014). Striking differences also exist in the ratio of operating theaters per population across countries at different economic levels: 25 per 100,000 in Eastern Europe, 14–15 in North America and Western Europe, 4–14 in Latin America and the Caribbean, 4.7 in East Asia, but only 1.3 in South Asia, and 1–1.2 in Sub-Saharan Africa (Funk and others 2010).

Two related WHO efforts have defined optimal infrastructure needs for first-level hospitals for surgical care in general (the Programme for Emergency and Essential Surgical Care [WHO 2015a]), and for trauma care at all levels of the health care system (the Essential Trauma Care Project [WHO 2015b]). Surveys conducted using these WHO guidelines and tools have shown the consistent absence of many low-cost pieces of equipment and supplies, such as chest tubes, oxygen, and equipment for airway management and anesthesia, in many locations, but especially in LICs and at first-level hospitals. In some cases, items are physically present but nonfunctional, such as equipment awaiting repairs. Often, equipment is functional, but it is only available to those who can pay, sometimes in advance; many of those who need the services are unable to access them (Belle and others 2010; Kushner and others 2010; Mock and others 2004, 2006; Ologunde and others 2014; Vo and others 2012; WHO 2003; WHO 2015a; WHO 2015b).

Approaches to Improve Access. Some institutions and health systems have successfully overcome these barriers. For example, the Hanoi Health Department steadily improved its physical resources for trauma care in its network of clinics and hospitals. Such improvements have been stimulated in part by research defining substantial gaps in availability of low-cost items recommended in the WHO’s Guidelines for Essential Trauma Care and by advocacy to remedy those gaps (Nguyen and Mock 2006). There have also been improvements in the availability of human resources for surgical care. For example, the establishment of the Ghana College of Physicians and Surgeons in 2003 created the first in-country credentialing process for surgeons and led to an expansion of the workforce of fully trained general surgeons and obstetricians. As of June 2014, 284 specialist surgeons and obstetrician-gynecologists had graduated from the college and been posted to first- and second-level hospitals throughout the country to serve as both providers and trainers.

It will likely be impossible to expand access to essential surgical services in rural areas of LMICs in the foreseeable future by depending only on fully certified surgeons and anesthesiologists. Innovative solutions to the surgical workforce crisis are imperative. Evidence shows that mid-level operators can safely perform a number of essential surgical procedures, provided they are properly trained and supervised and perform the operations frequently (McCord and others 2009; Pereira and others 2011). In some locations, these operators are general practitioners. In other cases, they are nonphysician clinicians (NPCs), such as técnicos de cirurgia (TCs) in Mozambique or assistant medical officers (AMOs) in Tanzania.

Outcomes such as maternal and neonatal mortality rates after cesarean section and other emergency obstetric procedures were similar for AMOs, compared with doctors in Tanzania (McCord and others 2009; Pereira and others 2011). Although cost studies are few, preliminary evidence shows the cost-effectiveness of task-sharing. For example, in Mozambique, it was three times more cost-effective to train and deploy TCs than to train and deploy physicians to provide obstetric surgery; the 30-year cost per major operation was US$40 for TCs and US$140 for physicians (Kruk and others 2007). Similarly, emergency obstetric care provided by general practitioners was found to be more cost-effective than that provided by fully trained obstetricians in Burkina Faso (Hounton and others 2009).

NPCs are more likely than physicians to stay in underserved rural areas, and they are less likely to emigrate, so their deployment significantly increases the availability of surgical services in underserved rural areas. In Mozambique and Tanzania, NPCs perform about 90 percent of major emergency obstetric surgery in rural areas where most of the population live (Bergström and others 2015). Challenges continue for many countries, including physicians’ acceptance of NPCs, as well as of standardizing their training, supervision, regulatory mechanisms, continuing skills improvement, and remuneration and nonfinancial incentives. The long-range goal is expanding the number of fully trained surgeons. However, general practitioners and NPCs, with appropriate support from surgeons, can be an important intermediate solution to the problem of access to basic surgery.

Many essential physical resources, such as equipment and supplies, are low cost and could be better supplied through improved planning and logistics. The availability of some of the more expensive items, such as x-ray machines and ventilators, would be improved by research on product development. Such research should address improved durability, lower cost of both purchasing and operating, and increased ease of operation. Similarly, the availability of many items could be improved by increased capabilities for local manufacture (WHO 2012). However, international assistance for provision of basic essential equipment and supplies will be needed for the immediate future for the poorest countries. An often overlooked ingredient is the need to ensure local capacity to maintain and repair equipment.

Population, policy, and implementation research (PPIR) could contribute by identifying more efficient and lower-cost delivery methods. The WHO has made significant contributions by establishing norms for human and physical resources for surgical and trauma care and by documenting success stories of individual countries (Mock and others 2004; WHO 2010; WHO 2015b); this is a role for the WHO and other stakeholders that should be expanded.

Surgical training has traditionally emphasized decision making and operative technique for individual patient care; this is appropriate, given the clinical role that most surgeons play. However, those surgeons who wish to address the systems-level barriers to achieving UCES will need additional skills in management and supervision of health care systems, quality improvement (QI), and public health.

A considerable additional barrier to access to surgical care is financial, especially in situations in which user fees are high or where out-of-pocket payments are required. The cost of surgical care is also a significant contributor to medical impoverishment (Schecter and Adhikari 2015). Including UCES within universal public finance would remove financial barriers to access to essential surgical care and would offer financial risk protection, as discussed in the conclusions of this chapter.

Improving the Safety and Quality of Anesthesia and Surgery

Surgical care in all settings is fraught with hazards, including risks from the diseases themselves, the operation, and the anesthesia. These hazards translate into dramatically different risks of death and other complications in different settings. For example, compared with Sweden’s rate of 0.04 deaths per 1,000 cesarean sections, mortality is at least 2–4 times higher in Latin America and the Caribbean, 6–10 times higher in South Asia, and 100 times higher in Sub-Saharan Africa (Hogberg 1989; Weiser and Gawande 2015).

A large component of the differences in postoperative mortality is due to differences in anesthesia-related mortality. Major advances have occurred in anesthesia safety in high-income countries (HICs), primarily due to improved monitoring and increased standardization and professionalization. In wealthier countries (those with higher scores on the human development index), mortality per million anesthetics has decreased from 357 deaths per million anesthetics before 1970 to 25 deaths per million anesthetics in the 1990s–2000s, but high rates of anesthetic deaths remain prevalent in most LMICs. Deaths solely attributable to anesthesia are estimated to occur at a rate of 141 deaths per million anesthetics in poorer countries, that is, those with lower score on the human development index, in comparison with the noted 25 deaths per million anesthetics in wealthier countries (Bainbridge and others 2012).

Many of the deaths and complications from surgery in LMICs are potentially preventable with three specific affordable and sustainable improvements:

  • Use of a surgical safety checklist
  • Improved monitoring and related safety practices during anesthesia
  • Improved systems-wide monitoring and evaluation of surgical care overall.

The use of the simple, 19-item WHO Surgical Safety Checklist across eight countries was found to double adherence to basic perioperative safety standards (Haynes and others 2009; WHO 2008a), such as confirmation of the procedure and operative site, objective airway assessment, and completion of instrument and sponge counts at the end of the procedure. Use of the checklist reduced deaths by 47 percent (the postoperative death rate fell from 1.5 percent before introduction of the checklist to 0.8 percent afterward) and inpatient complications by 35 percent, from 11 percent to 7 percent. The checklist improved outcomes in HICs and upper-middle-income countries (UMICs), LMICs, LICs, and in elective and emergency cases.

The safety of anesthesia in HICs has been achieved by adopting standards of care, such as the continuous presence of a trained anesthesia provider and uninterrupted monitoring of oxygenation, ventilation, and perfusion (Eichhorn and others 1986). Anesthesia delivery systems have been better standardized, with safety features engineered into the machines. One critical technology is pulse oximetry, an essential standard in HICs, which allows ongoing monitoring of oxygenation status so that problems can be corrected early, before they lead to serious or lethal consequences. In one study in Moldova, the introduction of a surgical safety checklist and pulse oximetry led to a significant drop in the number of hypoxic episodes and in the complication rate (Kwok and others 2013). A barrier to pulse oximetry availability has been its cost, although a concerted global effort is underway to lower these costs and increase its availability in LMICs. With lower-cost options now available, the cost-effectiveness of introducing pulse oximetry appears very favorable (Burn and others 2014).

Improved monitoring and evaluation of surgical care across institutions, such as through QI programs, help to better inform administration and management. QI programs range from very simple outcome assessments, such as morbidity and mortality conferences, to more complex monitoring, such as surveillance of complications and use of risk-adjusted mortality. Many hospitals in LMICs have some type of basic QI activities. The effectiveness of these activities could be increased by simple measures, such as more systematic recording of proceedings, more purposeful enactment of corrective action, and monitoring of the outcome of corrective action. A WHO review of QI programs for trauma care shows that most programs led to improvements in patient outcomes, including mortality, or process of care; many also reported cost savings (Juillard and others 2009). Although most of the programs were in HICs, two were in Thailand, an upper-middle-income country, where a model QI program led to sustained improvements in both process of care and mortality rates. Despite their effectiveness, simplicity, and affordability, QI programs are at a rudimentary level of development and implementation in most LMICs (Juillard and others 2009; Mock and others 2006).

An important role for the international community is to support PPIR that (1) addresses affordable and sustainable methods to improve quality of care and (2) documents and disseminates specific case studies of sustaining good practices. The WHO has already made significant contributions by establishing norms, such as the Surgical Safety Checklist (WHO 2008a). This role of governments, the WHO, and other stakeholders needs to be expanded, by establishing and promoting standards for safer, lower-cost anesthesia machines, and norms for monitoring and evaluation procedures for surgical care. Definition and tracking of a variety of quality indicators, such as the perioperative mortality rate needs to be better globally (McQueen 2013; Weiser and others 2009).

Surgery: A Core Component of Universal Health Coverage

Our results point to the potential for essential surgery to cost-effectively address a large burden of disease. Moreover, there are several viable short- and longer-term options for improving access to and safety and quality of surgical care. Figure 1.3 illustrates alternative uses for incremental resources in light of these findings. A country’s situation today could be portrayed as a point in the cube: its position on dimension Q depicts the current average quality of care. Its position on dimension A reflects the proportion of the population with access to care, and its position on dimension R reflects the range of services available. Investment choice requires assessment of whether to put incremental money into improving access, improving average quality, or increasing the range of services to be offered. Our interpretation of the results presented is that it will generally prove both equitable and efficient to achieve full access to essential surgery at high quality before committing public resources to expanding the range of services for a smaller percentage of the population. The shading in figure 1.3 depicts this situation, which we have termed UCES. UCES should appear early on the pathway to UHC (Jamison, Summers, and others 2013).

Figure 1.3. Dimensions of Universal Coverage of Essential Surgery.

Figure 1.3

Dimensions of Universal Coverage of Essential Surgery.

Other surgical conditions and procedures merit consideration, such as those for cancer; vascular disease; and conditions requiring more advanced treatments, such as transplantation. Improving access to these procedures will also provide benefits. With regard to sequencing and use of public funds, efforts to ensure greater access to the essential services should be undertaken first, relative to increased investment in those conditions that are more expensive to treat or that have smaller health impacts.


There is a high burden of avertable death and disability from conditions that can be successfully treated by surgery. Many of the surgical procedures and capabilities needed to treat these conditions are among the most cost-effective of all health interventions and most in demand from the population. These include procedures to treat injuries, obstetric complications, abdominal emergencies, cataracts, obstetric fistula, and congenital anomalies. Many of the most needed procedures are affordable and feasible to deliver, but improving their coverage and quality will require a focused effort to strengthen the health system, particularly at first-level hospitals.

With the exception of obstetric care, the global health community has largely failed to address the unmet need for surgery. The surgical community, in turn, has not tackled the broader requirements for incorporating surgery into resource-constrained health systems—with the important exceptions of exploring task-sharing and improving quality of care.

Ensuring access to essential surgical services for everyone who needs them, when they need them, is in part about improving training in safe surgical care and technique, and in part about improving the functioning of health systems, including better monitoring and evaluation, developing appropriate financing mechanisms, and promoting equity, social justice, and human rights. The global system can play an important role in these efforts through informed leadership and advocacy, support for PPIR, and financial transfers to LICs to assist in attaining UCES.

Improved access to essential surgery should be implemented early in the path to UHC as part of the overall essential benefit package advocated by the Commission on Investing in Health (Jamison, Summers, and others 2013). Implementation would include measures such as using public funds to ensure access to essential surgery and including essential surgery in the packages covered by national health insurance schemes. Such measures would also offer financial risk protection against medical impoverishment from the costs of surgical care. Surgery should be considered an indispensable component of a properly functioning health system and can indeed be a means for strengthening the entire system, thereby increasing the return on investment (Jamison, Summers, and others 2013; WHO 2008b). Investments to provide and maintain equipment and to ensure a steady flow of supplies required for a functioning surgical service can strengthen the supply chain for an entire facility.

The nascent literature in this area also suggests positive spillovers between surgical investments and the functioning of and demand for health care. For example, upgrading facilities to provide surgery improved the confidence of providers in their facility and in their own clinical skills in Uganda (Kruk, Rabkin, and others 2014). Several studies show that availability of surgical services increased demand for health care in potentially high-risk conditions, such as labor and delivery or emergency care (Kruk, Hermosilla, and others 2014; Yaffee and others 2012).

Commitments by national governments and the international community to UCES would substantially reduce the mortality and suffering from treatable surgical conditions. Such commitments would also protect populations from financial risk and contribute to the development of the broader health system.


The Bill & Melinda Gates Foundation provides financial support for the Disease Control Priorities Network project, of which this volume is a part. The following individuals provided valuable comments and assistance on this chapter: Elizabeth Brouwer, Rachel Cox, Anna Dare, Sarah Greenberg, Andrew Leather, Rachel Nugent, Zachary Olson, and Gavin Yamey.

Members of the DCP3 Essential Surgery Author Group wrote the chapters on which this initial chapter draws. The Group includes Richard M. K. Adanu, Sweta Adhikari, Asa Ahimbisibwe, Blake C. Alkire, Joseph B. Babigumira, Jan J. Barendregt, Jessica H. Beard, Staffan Bergström, Stephen W. Bickler, David Chang, Anthony Charles, Meena Cherian, Thomas Coonan, Dawit Desalegn, Catherine R. deVries, Delanyo Dovlo, Richard P. Dutton, Mike English, Diana Farmer, Magda Feres, Zipporah Gathuya, Richard A. Gosselin, Hideki Higashi, Susan Horton, Renee Hsia, Kjell Arne Johansson, Clark T. Johnson, Timothy R. B. Johnson, Manjul Joshipura, Nicholas J. Kassebaum, Ramanan Laxmi-narayan, Carol Levin, Katrine Lofberg, Svjetlana Lozo, Jackie Mabweijano, Colin McCord, Barbara McPake, Kelly McQueen, John G. Meara, Nyengo Mkandawire, Mark A. Morgan, Mulu Muleta Bedane, Arindam Nandi, Richard Niederman, Emilia V. Noormahomed, Florian R. Nuevo, Eyitope Ogunbodede, Michael Ohene-Yeboah, Andrew Ottaway, Doruk Ozgediz, Caetano Pereira, Mary Lake Polan, N. Venkatesh Prajna, Raymond R. Price, Shankar Prinja, Thulasiraj D. Ravilla, Eduardo Romero Hicks, Sarah Russell, William P. Schecter, Nicole Sitkin, Ambereen Sleemi, David Spiegel, Mark G. Shrime, Sathish Srinivasan, Andy Stergachis, Amardeep Thind, Stéphane Verguet, Jeffrey R. Vincent, Michael Vlassoff, Johan von Schreeb, Theo Vos, Thomas G. Weiser, Iain H. Wilson, and Ahmed Zakariah.


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World Bank Income Classifications as of July 2014 are as follows, based on estimates of gross national income (GNI) per capita for 2013:

  • Low-income countries (LICs) = US$1,045 or less
  • Middle-income countries (MICs) are subdivided:
    • lower-middle-income = US$1,046 to US$4,125
    • upper-middle-income (UMICs) = US$4,126 to US$12,745
  • High-income countries (HICs) = US$12,746 or more.

© 2015 International Bank for Reconstruction and Development / The World Bank.

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Attribution—Please cite the work as follows: Debas, H. T., P. Donkor, A. Gawande, D. T. Jamison, M. E. Kruk, and C. N. Mock, editors. 2015. Essential Surgery. Disease Control Priorities, third edition, volume 1. Washington, DC: World Bank. doi:10.1596/978-1-4648-0346-8. License: Creative Commons Attribution CC BY 3.0 IGO

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Bookshelf ID: NBK333511PMID: 26741007DOI: 10.1596/978-1-4648-0346-8_ch1


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