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World J Surg. 2017 May;41(5):1218-1224. doi: 10.1007/s00268-016-3847-9.

An Evaluation of Preparedness, Delivery and Impact of Surgical and Anesthesia Care in Madagascar: A Framework for a National Surgical Plan.

Author information

M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar.
University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA.
Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar.
M/V Africa Mercy, Mercy Ships, Port of Cotonou, Benin.
Ministère de la Santé Publique, Antananarivo, Madagascar.
M/V Africa Mercy, Mercy Ships, Port of Cotonou, Benin.
Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA.
Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.
Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.



The Lancet Commission on Global Surgery (LCoGS) described the lack of access to safe, affordable, timely surgical, and anesthesia care. It proposed a series of 6 indicators to measure surgery, accompanied by time-bound targets and a template for national surgical planning. To date, no sub-Saharan African country has completed and published a nationwide evaluation of its surgical system within this framework.


Mercy Ships, in partnership with Harvard Medical School and the Madagascar Ministry of Health, collected data on the 6 indicators from 22 referral hospitals in 16 out of 22 regions of Madagascar. Data collection was by semi-structured interviews with ministerial, medical, laboratory, pharmacy, and administrative representatives in each region. Microsimulation modeling was used to calculate values for financial indicators.


In Madagascar, 29% of the population can access a surgical facility within 2 h. Surgical workforce density is 0.78 providers per 100,000 and annual surgical volume is 135-191 procedures per 100,000 with a perioperative mortality rate of 2.5-3.3%. Patients requiring surgery have a 77.4-86.3 and 78.8-95.1% risk of incurring impoverishing and catastrophic expenditure, respectively. Of the six LCoGS indicator targets, Madagascar meets one, the reporting of perioperative mortality rate.


Compared to the LCoGS targets, Madagascar has deficits in surgical access, workforce, volume, and the ability to offer financial risk protection to surgical patients. Its perioperative mortality rate, however, appears better than in comparable countries. The government is committed to improvement, and key stakeholder meetings to create a national surgical plan have begun.

[Indexed for MEDLINE]

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