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Surgery. 2014 Mar;155(3):365-73. doi: 10.1016/j.surg.2013.10.008. Epub 2013 Oct 11.

Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: operative capacities of 78 district hospitals in 7 low- and middle-income countries.

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Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. Electronic address:
Department of Surgery, University of Western Ontario, London, Ontario, Canada.
Department of Surgery, Massachusetts General Hospital, Boston, MA; Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA.
Division of General Surgery, University of British Columbia, Vancouver, BC, Canada.
Department of Surgery, Georgetown University Hospital, Washington, DC.
Global Surgical Consortium, Phoenix, AZ.
Department of Surgery, Duke University Medical Center, Durham, NC; Harvard School of Public Health, Boston, MA.
Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.



Surgery has been neglected in low- and middle-income countries for decades. It is vital that the Post-2015 Development Agenda reflect that surgery is an important part of a comprehensive global health care delivery model. We compare the operative capacities of multiple low- and middle-income countries and identify critical gaps in surgical infrastructure.


The Harvard Humanitarian Initiative survey tool was used to assess the operative capacities of 78 government district hospitals in Bangladesh (n = 7), Bolivia (n = 11), Ethiopia (n = 6), Liberia (n = 11), Nicaragua (n = 10), Rwanda (n = 21), and Uganda (n = 12) from 2011 to 2012. Key outcome measures included infrastructure, equipment availability, physician and nonphysician surgical providers, operative volume, and pharmaceutical capacity.


Seventy of 78 district hospitals performed operations. There was fewer than one surgeon or anesthesiologist per 100,000 catchment population in all countries except Bolivia. There were no physician anesthesiologists in any surveyed hospitals in Rwanda, Liberia, Uganda, or in the majority of hospitals in Ethiopia. Mean annual operations per hospital ranged from 374 in Nicaragua to 3,215 in Bangladesh. Emergency operations and obstetric operations constituted 57.5% and 40% of all operations performed, respectively. Availability of pulse oximetry, essential medicines, and key infrastructure (water, electricity, oxygen) varied widely between and within countries.


The need for operative procedures is not being met by the limited operative capacity in numerous low- and middle-income countries. It is of paramount importance that this gap be addressed by prioritizing essential surgery and safe anesthesia in the Post-2015 Development Agenda.

[Indexed for MEDLINE]

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