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World J Surg. 2016 Nov;40(11):2611-2619.

Bellwether Procedures for Monitoring and Planning Essential Surgical Care in Low- and Middle-Income Countries: Caesarean Delivery, Laparotomy, and Treatment of Open Fractures.

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Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA.
Department of Surgery, Yale New Haven Hospital, 1245 Chapel Street Apt 503, New Haven, CT, 06510, USA.
Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA.
Department of Surgery, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 53226, USA.
WHO Emergency and Essential Surgical Care Programme, The World Health Organization, Headquarters, Geneva, Switzerland.
Royal North Shore Hospital, Plastic, Reconstructive and Burns, Reserve Rd, St Leonards, NSW, 2065, Australia.
Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
Department of Surgery, Bhabha Atomic Research Center (BARC) Hospital, Mumbai, 94, India.
Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA.
The Harvard Program in Plastic Surgery, Boston, MA, 02114, USA.
Department of Orthopedics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Royal Australasian College of Surgeons, East Melbourne, VIC, Australia.
School of Medicine, Faculty of Health, Barwon Health, Deakin University, Geelong, VIC, Australia.
The Alfred Hospital and Monash University, Melbourne, VIC, 3051, Australia.
Nanyang Technological University, 50 Nanyang Drive, Research Techno Plaza, Level 4 X-Frontiers Block, Singapore, 637553, Singapore.



Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care.


We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures-which we term "bellwether procedures"-was associated with performing a full range of essential surgical procedures.


The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p < 0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures.


Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team.

[Indexed for MEDLINE]

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