Concerted action is urgently needed to reduce disparities in surgical care provision for more than 2 billion people who have inadequate access to surgical services. Attention is specifically required in low-income countries where there are low levels of surgical care and an estimated half of all operating theatres do not have vital surgical equipment, according to an Article published Online First in The Lancet.
Illnesses that need surgical treatment account for 11% of the global disease burden. Previous research has shown that although less than a third of the world's population live in high-income countries they receive nearly 75% of the 234 million surgical procedures done every year, while the poorest third of the world's people, who have higher surgical disease burdens per head, receive just 4% of operations. However, little is known about the causes of disparities in access to surgical provision between high-income and low-income countries, or about the adequacy of surgical services including facilities, staff, and equipment.
To quantify the regional differences in this unmet surgical need, Atul Gawande from Harvard School of Public Health, Boston, USA, and international colleagues estimated the number of operating theatres worldwide, described their distribution, and calculated the availability of operating theatre equipment.
Using data from 769 hospitals in 92 countries taking part in WHO's Safe Surgery Saves Lives initiative, the authors estimated the number of functional operating theatres. Additionally, they collected data on the availability of pulse oximetry* in 54 countries as an indicator of availability of essential anaesthesia and surgical equipment.
Overall, findings showed considerable disparity in the number of operating theatres and availability of essential surgical equipment worldwide. The number of theatres per head varied more than 20-fold between the subregions. The estimated number of operating theatres ranged from 1.0 per 100 000 people in west sub-Saharan Africa to 25.1 per 100 000 in Eastern Europe.
All high-income sub-regions had more than 14 operating theatres per 100 000 people, compared to all low-income subregions that had fewer than two. Overall, the authors estimated that more than 2 billion people are without adequate access to surgical care.
Additionally, the authors estimated that 19% (77 700) of the world's operating theatres were not equipped with pulse oximeters, corresponding to around 32 million operations undertaken each year without these devices. In poor countries they calculated the devices to be absent more than half of the time.
The authors say: "Although this unmet surgical need has been known about for several decades, it has not been quantified in a way that can guide public health leaders and ministers towards effective solutions."
They conclude: "The disparity in operating theatre and equipment availability between resource rich and poor countries is substantial and its reduction will be very important for public health. We need informed initiatives targeted towards reduction of these barriers to accessible and safe surgical care, which would have a profound effect on global health."
In an accompanying Comment, Paul Myles from Alfred Hospital and Monash University, Melbourne, Australia, and Guy Haller from the University of Geneva, Switzerland, say that the study raises awareness of the inequality of access to safe and effective surgery around the world and highlights where more work is needed.
However they caution: "The study does not provide a full representation of the extent of inequity between regions and countries. Is the number of operating theatres or the number of trained personnel the cause of this inequity? Is pulse oximetry a valid and reliable indicator of quality in surgical care?" They suggest that consideration must also be given to what is necessary to provide safe care in an operating theatre.
Dr Atul Gawande, Harvard School of Public Health, Boston, USA. T) +1 617 571 2421 E) agawande@partners.org
Dr Paul Myles, Alfred Hospital and Monash University, Melbourne, Australia. E) p.myles@alfred.org.au
For full Article and Comment see: http://press.thelancet.com/tlsurgery.pdf
Notes to Editors: *Pulse oximetry is internationally recognised as an essential monitoring device for safe surgery (often unavailable in low-income settings), the absence of which might suggest a lack of other essential surgical equipment.
Journal
The Lancet