Despite surgery patients in Africa being younger, with a lower risk, having more minor surgery, and having fewer complications, their risk of death is double the global average, according to the most comprehensive study of surgery in Africa published in The Lancet.
The observational study, which was conducted by a group of more than 30 African researchers and includes 247 hospitals in 25 African countries, suggests that scarce workforce and resources mean surgery is less safe across the region. To improve these outcomes it calls for improved monitoring of patients during and soon after their surgery.
Surgery is a cost-effective and important component of universal healthcare, however it is estimated that five billion people worldwide are unable to access safe surgical treatment, and 94% of these people live in low- and middle-income countries.
"Approximately one in five surgery patients in our African cohort developed a complication, and, overall, 2% of all patients died," says lead author Professor Bruce Biccard, Groote Schuur Hospital and University of Cape Town, South Africa. "Our study reveals the scarce workforce resources available to provide safe surgical treatment. Although increased access to surgery is important, it is essential that that these surgical treatments are safe and effective. Importantly, 95% of deaths in our study occurred in the postoperative period, suggesting that many lives could be saved by effective monitoring of patients who have developed complications and increasing the resources necessary to achieve this objective. Surgical outcomes will remain poor in Africa until the problem of under-resourcing is addressed." 
The study includes data from 11422 people who underwent an inpatient surgical procedure during a set week at each of the 247 hospitals included across 25 African countries . Data on complications were missing for 537 people and data on mortality were missing for 229 people.
As well as documenting each patient's health before surgery, the study monitored their health after the surgery, tracking any complications, admission to critical care, or deaths. The study also reviewed hospital resources, such as numbers of beds, operating rooms, critical care beds, anaesthetists, surgeons, and obstetricians.
Overall, most patients (87.3%) had a good physical status and were low-risk for surgery, and were young (average age of 38.5 years). The majority of surgeries in the study were urgent or emergent (57.1% of surgeries) and the most common procedure was caesarean section (33.3% of all surgeries).
Complications following surgery occurred in 18.2% of all patients (1977/10885 people), and the most common complications were infections, accounting for 58.7% of all complications (1156/1970). Around 16.3% of patients (321/1972 people) were admitted to critical care to treat complications. One in ten patients with complications died (9.5%, 188/1970 people), and these deaths were spread equally across infectious (112 deaths), cardiovascular (110 deaths) and other complications (112 deaths) .
Overall, 2.1% of patients died after surgery (239/11193). Of these, 14 people (5.9%) died on the day of their surgery, and the average time to death was five days. Comparisons with international data for elective surgery suggest that death rates following surgery in Africa are twice the global average. Data from the study published today found that death rates from elective surgery were 1% in Africa, compared with 0.5% for the global average.
However, resources are scant, with each hospital included in the study serving an average population of 810000 people, with an average of 300 beds, four operating rooms, and three critical care beds.
Having few specialists and low procedural volumes also contributes to the low safety of surgery across African countries. Typically, each hospital completed 29 surgeries in a week, equivalent to 212 operations per 100000 people. The authors note that this is low, and indicates that services are not meeting need.
Overall, there were 0.7 specialists (a combined total of surgeons, obstetricians and anaesthesiologists) to every 100000 people in the hospital population, which the authors note is well below the recommended levels of 20-40 specialists per 100000 patients needed to reduce mortality. On average, each hospital had three specialist surgeons, one specialist anaesthetist and two specialist obstetricians.
The study furthers the work of The Lancet Commission on Global Surgery  which was published in 2015, and called for robust data on surgical activity and patient outcomes. The Commission states that structures, processes and outcomes are important parts to improve the quality of surgery worldwide.
"Our study highlights the importance of effective perioperative care to achieve better surgical outcomes in Africa. A continent-wide quality improvement programme might reduce the number of preventable deaths following surgery in Africa." adds Professor Biccard .
The authors note some limitations, including that the study does not include data for all African countries, including many low-income countries, or for smaller, more remote hospitals, and so the findings might not be applicable for detailed health policy decisions in individual countries or hospitals.
Additionally, the week-long period of data collection means that wider changes, which may influence health care access - such as seasonal weather, industrial action, available workforce, armed conflict, workload, and when people choose to access healthcare - may not be accounted for.
Writing in a linked Comment, Dr Anna Dare from University of Toronto, Canada, Bisola Onajin-Obembe from the University of Port Harcourt, Nigeria, and Emmanuel Makasa from University of Witwatersrand, South Africa, say: "Although the main aim of Biccard and colleagues' study was to quantify surgical outcomes, the most alarming finding was how few people actually received surgery. Surgical volume (the number of operations per 100 000 population) is an indicator of met need for surgical care. The ASOS findings suggested that this is unacceptably low in Africa. Among the 25 countries who contributed data, only a median 212 operations (IQR 65-578) were done per 100 000 catchment population. These numbers are 20 times lower than the crucial surgical volume required to meet a country's essential surgical needs each year (defined as 5000 operations per 100 000 people), although the study did exclude paediatric patients-- an important cohort given the continent's population structure. Although strategies to improve perioperative care processes and structural quality are urgently needed, and might be easier to implement in the short term, the absence of surgery in Africa represents a silent killer that probably claims more lives. Identified barriers to accessing surgery in LMICs include cost, distance to care, and fear of surgery. To measure effective coverage of surgical care--which is predicated on surgical access, volume, and quality--countries will therefore need to track more than one surgical indicator."
NOTES TO EDITORS
This study was funded by the Medical Research Council of South Africa. It was conducted by researchers from University of Cape Town, University of KwaZulu-Natal, University of Pretoria, University Hospital of Kinshasha, University of Zimbabwe College of Health Sciences, Ministry of Health and Social Services Namibia, Faculté de médicine de Bamako, Jawaharlal Nehru Hospital, Francis Small Teaching Hospital, National Hospital of Niamey, University of Ibadan, University College Hospital, Ibadan, Makerere University, Stellenbosch University, McMaster University and Population Health Research Institute, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Tripoli Medical Centre, Universitar Hospital, Algeria, Hôpital de la mère et de l'enfant, Kamenge Teaching Hospital, Baptist Hospital, Mater Hospital, University of Nairobi School of Medicine, University Teaching Hospital, Addis Ababa University, Kwame Nkrumah University of Science and Technology, Christian Social Service Commission, Sylvanus Olympio University Teaching Hospital, Cairo University, Queen Mary University of London.
 Quote direct from author and cannot be found in the text of the Article.
 These countries included 14 low-income countries (Benin, Burundi, Congo, Democratic Republic of the Congo, Ethiopia, The Gambia, Madagascar, Mali, Niger, Senegal, Tanzania, Togo, Uganda, and Zimbabwe) and 11 middle-income countries (Algeria, Cameroon, Egypt, Ghana, Kenya, Libya, Mauritius, Namibia, Nigeria, South Africa, and Zambia).
 The number of deaths associated with each type of complications added together (ie, 112 deaths from infectious complications, 110 cardiovascular deaths, and 112 other complications) comes to more than the total amount of deaths (ie, 188 deaths) because some deaths were associated with more than one complication.
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