Elsevier

The Lancet

Volume 372, Issue 9633, 12–18 July 2008, Pages 139-144
The Lancet

Articles
An estimation of the global volume of surgery: a modelling strategy based on available data

https://doi.org/10.1016/S0140-6736(08)60878-8Get rights and content

Summary

Background

Little is known about the amount and availability of surgical care globally. We estimated the number of major operations undertaken worldwide, described their distribution, and assessed the importance of surgical care in global public-health policy.

Methods

We gathered demographic, health, and economic data for 192 member states of WHO. Data for the rate of surgery were sought from several sources including governmental agencies, statistical and epidemiological organisations, published studies, and individuals involved in surgical policy initiatives. We also obtained per-head total expenditure on health from analyses done in 2004. Major surgery was defined as any intervention occurring in a hospital operating theatre involving the incision, excision, manipulation, or suturing of tissue, usually requiring regional or general anaesthesia or sedation. We created a model to estimate rates of major surgery for countries for which such data were unavailable, then used demographic information to calculate the total worldwide volume of surgery.

Findings

We obtained surgical data for 56 (29%) of 192 WHO member states. We estimated that 234·2 (95% CI 187·2–281·2) million major surgical procedures are undertaken every year worldwide. Countries spending US$100 or less per head on health care have an estimated mean rate of major surgery of 295 (SE 53) procedures per 100 000 population per year, whereas those spending more than $1000 have a mean rate of 11 110 (SE 1300; p<0·0001). Middle-expenditure ($401–1000) and high-expenditure (>$1000) countries, accounting for 30·2% of the world's population, provided 73·6% (172·3 million) of operations worldwide in 2004, whereas poor-expenditure (≤$100) countries account for 34·8% of the global population yet undertook only 3·5% (8·1 million) of all surgical procedures in 2004.

Interpretation

Worldwide volume of surgery is large. In view of the high death and complication rates of major surgical procedures, surgical safety should now be a substantial global public-health concern. The disproportionate scarcity of surgical access in low-income settings suggests a large unaddressed disease burden worldwide. Public-health efforts and surveillance in surgery should be established.

Funding

WHO.

Introduction

Worldwide public-health initiatives have traditionally focused on surveillance and control of infectious disease, education, health promotion, and disease prevention. In recent decades, however, gains in life expectancy have changed previous trends of disease in low-income and middle-income countries, especially in the Middle East and Asia. With the so-called epidemiological transition that has accompanied industrialisation,1 disorders afflicting populations are shifting from diseases of pestilence and infection that are an indicator of pre-industrial societies to those that are identified in industrialised and rising economies.2, 3 Ischaemic heart disease, cerebrovascular disease, cancers, and mental illness have all risen substantially in low-income, middle-income, and high-income countries.4 Injuries also account for a large and growing amount of the disease burden as vehicular traffic and technical innovation increase around the world.5 These trends are bound to continue.

Surgical services have long been recognised to be an essential if often expensive component of the public-health system. Surgery occurs in every setting from the most resource rich to the most resource limited, and the need has increased greatly with the shifting patterns of disease. However, little is known about the actual worldwide volume and availability of surgical care since only anecdotal evidence exists.

Because of this epidemiological transition, surgery will assume an increasing role in public health. In view of its complexity and risks, an understanding of the quantity and distribution of surgical interventions is therefore essential to guide efforts to improve its safety and redress shortages of such services. As part of WHO's patient safety programme,6 we aimed to estimate the number of major operations undertaken worldwide, to describe their distribution, and to assess the importance of surgical care in global public-health policy.

Section snippets

Population and health databases

We gathered population and health data from WHO and the UN Population Fund. We obtained data for total population, average life expectancy, death rate from HIV/AIDS, physician density, nursing density, number of hospital beds, gross domestic product, literacy rate, percentage of the population living on less than US$1 per day, and percentage coverage of vital registration of death (which is an indication of the ability of a country's capacity to gather statistical information) from the WHO's

Results

We obtained surgical data for 56 (29%) of 192 WHO member states. Countrywide data were available for 48 countries; national totals for the remaining eight countries were extrapolated from data for a portion of the country. Of countries with countrywide data, 39 had specific data for the number of major surgical procedures from which we calculated a surgical rate on the basis of WHO population data, and nine provided rates of surgery from which we calculated the total volume of surgery for the

Discussion

We have estimated that the global volume of major surgery in 2004 was between 187·2 million and 281·2 million cases per year. This result translates into about one operation for every 25 human beings, which has substantial implications for public-health planning. It exceeds by nearly double the yearly volume of childbirth—an estimated 136 million births occurred in 200615—and is probably an order of magnitude more dangerous.16, 17, 18, 19, 20, 21, 22

Although death and complication rates after

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