Global Surgery 2030 REPORT OVERVIEW

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1 Global Surgery 2030 evidence and solutions for achieving health, welfare, and economic development REPORT OVERVIEW A collective call for equity and integration in the provision of surgical and anaesthesia care In January 2014, President of the World Bank, Dr. Jim Yong Kim, called for a shared vision and strategy for global equity in essential surgical care, stating surgery is an indivisible, indispensable part of health care. This call came at a pivotal time for global health. As focus transitions from the Millennium Development Goals to a set of Sustainable Development Goals (SDGs) and commitments to Universal Health Coverage (UHC), the global community must develop strategies to reach these new aims. Global Surgery 2030, the landmark initial report of The Lancet Commission on Global Surgery, describes the role of surgical and anaesthesia care in improving the health of individuals and the economic productivity of countries. Developed by a multidisciplinary team of 25 commissioners and collaborators from over 110 nations, the report presents findings on the state of surgical care in low-income and middle-income countries (LMICs), as well as a framework of recommendations, indicators and targets needed to achieve the Commission s vision of universal access to safe, affordable surgical and anaesthesia care when needed. These findings create a powerful argument to (1) governments in LMICs to strengthen surgical services and the national health systems that provide them, (2) global health and development organisations to include indicators of surgical care within existing health goals and monitoring systems, (3) funding agencies to invest in surgical care as a tool for poverty alleviation and general welfare gains, (4) international partners to support local leaders in their efforts to provide equitable surgical care, and (5) the general public to lobby for access to surgical services for all. Surgery as a neglected component of health systems Over the past twenty years, global health has focused primarily on individual diseases. This has led to remarkable reductions in death and disability from certain conditions. However, these gains have not been mirrored by similar improvements to health systems, integration of services, and hospital-based care, nor have they been equitably distributed amongst people of all socioeconomic standings. Surgical and anaesthesia care in many LMICs has been largely neglected Treatment for surgical conditions, a broad range of diseases that represent approximately 30% of the global burden of disease and span 100% of disease sub-categories, remains out of reach for the majority of the world s population. This results in loss of life and reduced welfare for millions of people, and stunts economic development of countries, as demonstrated by the report s five key messages % of the global burden of disease can be attributed to surgically treatable conditions

2 Key Message 1: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed Timely access to surgical care is essential to reduce death and disability from surgical conditions. Looking at four dimensions of access timeliness, surgical capacity, safety, and affordability we found that 5 billion people are unable to reach surgical services (Figure 1). Over half the global population cannot access the treatment they need should they, for example, haemorrhage after childbirth, suffer a burn, or develop cancer. Access to care is worse for individuals in LMICs, and for those in the poorest wealth quintiles within countries of all income groupings Target: 80% coverage of essential surgical and anaesthesia services The Commission has a target of 80% coverage of essential surgical and anaesthesia services per country by 2030 Figure 1. Proportion of the population without access to safe, affordable surgery and anaesthesia by region as a measure of progress towards timely access to surgery. Reaching this target will require integration of surgical services across all levels of care (from community referral networks to first-level and higher-level hospitals), and a commitment to address factors that result in delays in seeking, reaching, and receiving safe and affordable surgical and medical care. Key Message 2: 143 million additional surgical procedures are needed each year to save lives and prevent disability Estimated annual Region unmet surgical need of region (surgical cases) Caribbean Central Asia Central Europe Central sub-saharan Africa East Asia Eastern sub-saharan Africa North Africa and Middle East Oceania South Asia Southeast Asia Southern sub-saharan Africa Western sub-saharan Africa Global total Table 1. Regions with unmet need for surgical care as identified by the Lancet Commission on Global Surgery. When surgical care is not readily available, easily treatable conditions become diseases with high fatality rates. Obstructed labour results in death for both mother and infant; cleft lip and palate becomes an impediment to normal growth and development for a child, and a broken bone leads to life-long disability for a young man working to provide for his family. We found that performance of a minimum of 143 million additional surgical procedures are necessary each year to save lives and prevent disability (Table 1). This need is greatest in the poorest regions of the world, including Western, Eastern, and Central sub-saharan Africa, and South and Southeast Asia Target: 5,000 procedures per 100,000 population The Commission has a target of 5,000 procedures annually per 100,000 population by 2030 as a measure of met need for surgical and anaesthesia care. Reaching this target will require a broad expansion of surgical and health systems, including doubling of the surgical workforce within the next fifteen years. Expansion of surgical volume must be accompanied by a focus on quality, safety, and equity driven by local implementers.

3 Key Message 3: 33 million individuals face catastrophic health expenditure due to payment for surgery and anaesthesia each year Protection against catastrophic out-of-pocket payments for health care is a critical component to ensuring affordable access to essential health services. Catastrophic expenditure is defined as direct medical payments for surgical care that exceed 10% of total income or 40% of income after basic needs for food and shelter are met, and out-of-pocket payments are defined as private expenditures. We found that 33 million cases of catastrophic expenditure occur annually from the direct medical costs of surgical services, and an additional 48 million cases occur each year when non-medical costs, such as food and transportation expenses, are included. One quarter of all people who have a surgical procedure will face financial catastrophe as a result of seeking care. This financial burden falls most heavily on the poor. Financial catastrophe from seeking surgical care occurs most often for individuals in LMICs, and for those in the poorest wealth quintiles within countries of all income groupings Target: 100% protection against catastrophic expenditure The Commission has a target of 100% protection against catastrophic expenditure from out-of-pocket payments for surgical and anaesthesia care by Reaching this target will require an approach to financing surgical services that accounts for the needs of the poor, including financing mechanisms based on pooling of risk through general taxation or insurance models rather than user fees at the time of care. The Commission supports a progressive pathway to UHC that (1) commits to coverage for the poor from the beginning, and (2) includes surgery within all basic UHC packages, platforms, and relevant policies. Key Message 4: Investment in surgical and anaesthesia services is affordable, saves lives, and promotes economic growth Scaling up surgical and anaesthesia services to meet current population needs will require widescale financial investments in LMICs. If LMICs were to scale-up surgical services at an annual rate of 9% (a rate previously achieved by Mongolia, a high-performing country) to reach a surgical volume target of 5,000 procedures per 100,000 population, the total cost by 2030 would be approximately $420 billion. Although this financial cost of surgical expansion is significant, the cost of inaction on national incomes is much greater. The lost output (total GDP losses) will cost LMICs a total of $12.3 trillion dollars (Figure 2), reducing annual GDP growth as much as 2%. Figure 2. Annual and cumulative GDP lost in low-income and middle-income countries from five categories of surgical conditions (injury, neoplasm, neonatal, maternal, digestive) US$, purchasing power parity 16.9 million lives lost due to surgical conditions in 2010 An estimated 16.9 million lives were lost in 2010 from conditions requiring surgical care, and at least 77.2 million disability-adjusted life-years could be averted each year through provision of basic surgical services. Financing surgical expansion in a way that decreases death and disability for patients and maximizes economic benefits for countries is both feasible and cost-effective. However, it will require mobilization of domestic and international funding sources, as well as a commitment to surgical care as a component of national health services. Funding generation will be aided by increased transparency and accountability to monitor financial flows and innovative methods to reduce costs for both patients and health systems.

4 Key Message 5: Surgery is an indivisible, indispensable part of health care Surgical care is an integral component of health systems for all countries at all levels of development. Surgical services are required across all disease subcategories, throughout the life-course (from birth to death), and within all levels of care (from prevention to palliation). The burden of surgical conditions is growing both in total numbers as well as in relation to other health gains. When left untreated, these conditions exert substantial economic and welfare tolls on countries and their people. These damages are projected to grow exponentially. Safe, affordable surgical and anaesthesia care when needed is necessary to achieve local and global health goals, including prior commitments to improving individual diseases, efforts to strengthen the health and economic productivity of nations, and the new set of SDGs and targets for UHC, which both have 2030 end dates. Delivery of surgical services and essential procedures must be embedded within targets for the SDGs and UHC Policy makers, implementers and funders must include surgical care as a necessary part of national health and development strategies. A focus on equitable and high-quality care must accompany a commitment to financial risk protection to best care for patients with surgical conditions. Finally, successful change must be locally driven by local leaders and supported by global partners in order to achieve health, welfare, and economic development for all. Core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care when needed INDICATOR NAME Access to timely essential surgery Specialist surgical workforce density Surgical volume Perioperative mortality rate (POMR) Protection against impoverishing expenditure Protection against catastrophic expenditure TARGET A minimum of 80% coverage of essential surgical and anaesthesia services per country by % of countries with at least 20 surgical, anaesthesia and obstetric physicians per population by % of countries by 2020 and 100% of countries by 2030 tracking surgical 80% of countries by 2020 and 100% of countries by 2030 tracking POMR; 100% protection against impoverishment from OOP payments for surgical and anaesthesia care by % protection against catastrophic expenditure from OOP payments for surgical and anaesthesia care by 2030 Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development was written by The Lancet Commission on Global Surgery, an international multi-disciplinary group of 25 Commissioners, in consultation with collaborators in over 110 countries and all major regions of the world. The Commission is chaired by Dr. John Meara, Dr. Andy Leather, and Dr. Lars Hagander.

5 Global Surgery 2030 evidence and solutions for achieving health, welfare, and economic development Policy brief: INVESTING IN SURGICAL AND ANAESTHESIA CARE In September 2015, United Nations member states will adopt a new set of Sustainable Development Goals (SDGs) with a 2030 end date. A landmark report, called Global Surgery 2030: evidence and solutions for achieving health, welfare and economic development makes the case that sustainable development will be hard to achieve unless the international health and development community addresses the enormous global burden of surgical conditions. The report, by The Lancet Commission on Global Surgery, an international group of 25 health experts, shows that surgical conditions impede economic development in low-income and middle-income countries (LMICs), where access to surgical care is poor. Without urgent investment in the scale-up of surgical services, these conditions will be a major barrier to national income growth, economic productivity, and improved human welfare. Surgical scale-up will require mobilization of both domestic and international finance and resources in most LMICs. However the estimated costs are small relative to the economic and welfare returns on investment countries will experience. These findings provide a compelling rationale for national governments in LMICs, as well as donor agencies, to increase both investments in surgical services and in the national health systems required to support their delivery. The powerful economic case for investing in surgical care in LMICs Investing in scaling up surgical care in LMICs will dramatically improve public health by reducing death and disability. In addition, there is a powerful economic case for such investments: Surgical conditions impair economic productivity Surgical conditions, especially when left untreated, can reduce economic productivity. Global Surgery 2030 measures the value of lost economic output due to surgical conditions that is, the GDP losses that occur as a result of depletion of the labour supply and capital stock. The report shows that LMICs will have projected losses in economic productivity from surgical conditions estimated at $12.3 trillion (2010, US$, PPP) between , unless urgent scale-up of surgical care occurs (Figure 1). Figure 1. Annual and cumulative GDP lost in low-income and middle-income countries from five categories of surgical conditions. Based on the WHO Projecting the Economic Cost of Ill-Health (EPIC) model (2010 US$, purchasing power parity). GDP=gross domestic product.

6 These losses will have a profound effect on national income, reducing annual GDP growth by as much as 2% in lower-middle income countries (Figure 2). Most of these losses will occur as a result of injuries, cancers, digestive diseases, and maternal and neonatal conditions. Surgical conditions impede welfare gains Figure 2. Annual value of lost economic output due to surgical conditions. Data are percentage loss of GDP by World Bank income class, based on the WHO Projecting the Economic Cost of Ill-Health (EPIC) model (2010 US$, purchasing power parity). GDP=gross domestic product. Economic productivity, as captured in national income accounts and measured using the GDP, is only one way of measuring the returns on investing in surgical care. A limitation of using GDP is that it fails to capture the intrinsic value people place on improved health and on living longer. To quantify this intrinsic value, and how it is affected by surgical conditions, Global Surgery 2030 used a measure called the value of a statistical life (VSL), which places a monetary value on the trade-offs people are willing to make for an increase in life expectancy. Using this VSL method, the report finds that in LMICs in 2010, illness and death from surgical conditions resulted in $4.0 trillion (2010 US$ PPP) in total welfare losses. Surgical and anaesthesia care is highly cost-effective in LMICs Surgical services are a cost-effective health investment in resource-poor settings. Delivery of a platform of surgical and anaesthesia services at the first-level (district) hospital has proven to be very cost-effective in all major LMIC regions, as measured by WHO cost-effectiveness ratios. Such delivery compares favourably to the delivery of other common public health interventions in LMICs, such as childhood vaccines, HIV medicines, and distribution of bed nets to prevent malaria. Out-of pocket payments for surgical and anaesthesia care can cause catastrophic expenditure and impoverishment Although surgical care can be highly cost-effective as a health intervention, it can still be catastrophically expensive for individual patients if they have to pay out-of-pocket at the time they receive care. Out-of-pocket payment for surgical care occurs in many LMICs, because surgical interventions are not usually covered under publically- financed health care packages. Globally, 33 million people every year face catastrophic health expenditure through paying for surgical care (catastrophic expenditure is defined as direct medical payments for surgical care that exceed 10% of their total income or 40% of their income after their basic needs for food and shelter are met). A further 48 million people experience catastrophic expenditure when the non-medical costs of care, such as transport and food, are included. Most of these people live in LMICs. Many more people do not seek care at all, or decide not to pursue surgical treatment as advised because they cannot afford the costs.

7 Investing in surgical scale-up would have profound economic and welfare benefits Increasing access to safe, timely, and affordable surgical and anaesthesia care would produce substantial economic and welfare gains. Such gains will only be possible if countries and the international community commit to three key actions: Include essential surgical care within publically- financed health coverage policies To improve access to surgery in LMICs and reduce catastrophic health expenditure from seeking care, health financing mechanisms that offer financial risk protection (FRP) are needed. Such protection is defined as safeguarding people against the financial uncertainty associated with the need to use and pay for health services. For many LMICs, FRP means moving away from user fees for surgical care, paid out of pocket, to indirect financing mechanisms such as general taxation or insurance models, which pool risk. Many countries are moving to introduce universal health coverage (UHC) policies and packages, which aim to promote equity, quality, and FRP within national health systems and services. UHC policies must include surgery and should cover at minimum a basic package of essential surgical and anaesthesia care, the precise composition of which should be determined by country needs. Invest in the scale-up of surgical services within national health systems To meet population needs, surgical services and operative volumes in most LMICs will need to be substantially increased. The Commission examined different scenarios for scaling up surgical and anesthesia care from 2012 to 2030 in LMICs, based on achieving a minimum operative volume required to meet basic population needs (i.e procedures per 100,000 population). To achieve rates of surgical growth similar to a current best-performing LMIC (Mongolia), the total scale-up costs for 88 LMICs during would be about $420 billion. This number represents 1% of current total annual health expenditures in upper-middle income countries, and about 6% and 8% for lower-middle income and low-income countries respectively. Scale-up of surgical services in upper-middle income countries could be meet through domestic health financing, but lower-middle income and low-income countries will require both domestic and international financing. Although the costs of scale-up are large, the costs of inaction are greater, and will accumulate progressively unless urgent action is taken. Monitor financial flows to surgical care to ensure accountability and transparency An understanding of domestic and international financial flows to surgical care is crucial to quantify the current financing gap for surgery in LMICs at the country level. Currently financial flows are poorly tracked, as the major national and international health databases do not collect surgeryspecific data. Improved tracking of surgical financing flows within national health accounts and databases of international development assistance for health is required to identify funding gaps, ensure that resources materialize from promises, and encourage accountability and transparency. Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development was written by The Lancet Commission on Global Surgery, an international multi-disciplinary group of 25 Commissioners, in consultation with collaborators in over 110 countries and all major regions of the world. The Commission is chaired by Dr. John Meara, Dr. Andy Leather, and Dr. Lars Hagander.

8 Global Surgery 2030 Core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care when needed Indicator Definition Rationale Data Sources Responsible Entity Comments Target Group 1: Preparedness for surgical and anaesthesia care Access to timely essential surgery Specialist surgical workforce density Proportion of the population that can access, within 2 hours, a facility that can do caesarean delivery, laparotomy and treatment of open fracture (the Bellwether procedures) Number of specialist surgical, anaesthetic and obstetric physicians who are working, per population Group 2: Delivery of surgical and anaesthesia care All people should have timely access to emergency surgical services. Bellwether procedure performance predicts accomplishment of many other essential surgical procedures; 2 hours is a threshold of death from complications of childbirth The availability and accessibility of human resources for health is a crucial component of surgical and anaesthesia care delivery Facility records and population demographics Facility records, data from training and licensing bodies Ministry of Health Ministry of Health Informs policy and planning regarding location of services in relation to population density, transport systems and facility service delivery Informs workforce, training and retention strategies A minimum of 80% coverage of essential surgical and anaesthesia services per country by % of countries with at least 20 surgical, anaesthetic, and obstetric physicians per population by 2030 Surgical volume Procedures done in an operating theatre, per population per year The number of surgical procedures done per year is an indicator of met need Facility records Facility, Ministry of Health Informs policy and planning regarding met and unmet need for surgical care 80% of countries by 2020 and 100% of countries by 2030 tracking surgical volume; procedures per population by 2030 Perioperative mortality rate (POMR) All-cause death rate prior to discharge among patients who have undergone a procedure in an operating theatre, divided by the total number of procedures, presented as a percentage Group 3: Impact of surgical and anaesthesia care Protection against impoverishing expenditure* Protection against catastrophic expenditure Proportion of households protected against impoverishment from direct out-of-pocket payments for surgical and anaesthesia care Proportion of households protected against catastrophic expenditure from direct out-ofpocket payments for surgical and anaesthesia care Surgical and anaesthesia safety is an integral component of care delivery; perioperative morality encompasses deaths in the operating theatre and in the hospital after the procedure Billions of people each year are at risk of financial ruin from accessing surgical services; this is a surgery-specific version of a World Bank universal health coverage target Billions of people each year are at risk of financial ruin from accessing surgical services; this is a surgery-specific version of a World Bank universal health coverage target Facility records and death registries Household surveys, facility records Household surveys, facility records Facility, Ministry of Health World Bank, WHO, USAID World Bank, WHO, USAID Informs policy and planning regarding surgical and anaesthesia safety, as well as surgical volume when number of procedures is the denominator Informs policy about payment systems, insurance coverage, and balance of public and private services Informs policy about payment systems, insurance coverage, and balance of public and private services 80% of countries by 2020 and 100% of countries by 2030 tracking perioperative mortality; in 2020, assess global data and set national targets for % protection against impoverishment from out-of-pocket payments for surgical and anaesthesia care by % protection against catastrophic expenditure from outof-pocket payments for surgical and anaesthesia care by 2030 Access, workforce, volume, and perioperative mortality indicators should be reported annually. Financial protection indicators should be reported alongside the World Bank and WHO measures of financial risk protection for universal health coverage. These indicators provide the most information when used and interpreted together; no single indicator provides an adequate representation of surgical and anaesthesia care when analysed independently. USAID=US Agency for International Development. Equity stratifiers are listed in report s discussion. *Impoverishing expenditure is defined as being pushed into poverty or being pushed further into poverty by out-of-pocket payments. Catastrophic expenditure is defined as direct out-of-pocket payments of greater than 40% of household income net of subsistence needs.

9 Global Surgery 2030 Template for a National Surgical Plan Infrastructure Components Recommendations Assessment Methods Track number and distribution of surgical facilities Negotiate centralised framework purchase agreements with decentralised ordering Proportion of population with 2 hour access to first-level facility Surgical facilities Equip first-level surgical facilities to be able to perform laparotomy, caesarean delivery WHO Hospital Assessment Tool (eg, assessment of structure, Facility readiness and treatment of open fracture (the Bellwether Procedures) electricity, water, oxygen, surgical equipment and supplies, computers Blood supply Develop national blood plan and internet) Access and referral systems Reduce barriers to access through enhanced connectivity across entire care delivery chain Proportion of hospitals fulfilling safe surgery criteria from community to tertiary care Blood bank distribution, donation rate Establish referral systems with community integration, transfer criteria, referral logistics, protections for first-responders and helpful members of the public Workforce Components Recommendations Assessment Methods Surgical, anaesthetic and Establish training and education strategy based on population and needs of country Density and distribution of specialist surgical, anaesthetic, and obstetric providers obstetric providers Require rural component of surgical and anaesthetic training programmes Allied health providers Number of surgical, anaesthetic and obstetric graduates and retirees Develop a context-appropriate licensing and credentialing requirement for all surgical (nursing; operational managers; biomedical engineers; Training and education strategy of ancillary staff based on population and needs of Presence of task sharing or nursing accredited programs and number of workforce Proportion of surgical workforce training programmes accredited country providers radiology, pathology and Invest in professional health-care manager training Presence of attraction and retention strategies laboratory technician Establish biomedical equipment training programme Density and distribution of nurses, ancillary staff including operational officers) managers, biomedical engineers, and radiology, pathology and laboratory technicians Service Delivery Components Recommendations Assessment Methods All first-level hospitals should provide laparotomy, caesarean delivery and treatment of open fracture (the Bellwether Procedures) Surgical volume Integrate public, private, NGO providers into common national delivery framework; promote demand-driven partnerships with NGOs to build surgical capacity Proportion of surgical facilities offering the Bellwether Procedures System coordination Prioritise healthcare management training Number of surgical procedures done per year Quality and safety Prioritise quality improvement processes and outcomes monitoring Surgical and anaesthetic related morbidity and mortality (perioperative) Promote telemedicine to build system-wide connectivity Availability of system-wide communication Promote system-wide connectivity for telemedicine applications, clinical support and education Financing Components Recommendations Assessment Methods Health financing and Surgical expenditure as a proportion of gross domestic product Cover basic surgical packages within universal health coverage accounting Surgical expenditure as a proportion of total national health-care budget Risk pool with a single pool; minimise user fees at the point of care Budget allocation Out-of-pocket expenditures on surgery Track financial flows for surgery through national health accounts Catastrophic and impoverishing expenditures on surgery Use value-based purchasing with risk-pooled funds Information Management Component Recommendations Assessment Methods Information systems Presence of data systems that promote monitoring and accountability Develop robust information systems to monitor clinical processes, cost, outcomes and related to surgical and anaesthesia care Research agenda identify deficits Proportion of hospital facilities with high speed internet connections Identify, regulate, and fund surgical research priorities of local relevance The components addressing surgical care should be incorporated within a broader strategy of improvement of national health systems. NGO = non-governmental organization. WHO = World Health Organization

10 Global Surgery 2030 evidence and solutions for achieving health, welfare, and economic development Policy Brief: ACTIONS AND OPPORTUNITIES FOR THE INTERNATIONAL COMMUNITY Realising global health, welfare, and development goals during the period will not be possible without improving access to safe and affordable surgical care when needed for those living in low-income and middle-income countries (LMICs). The landmark report, Global Surgery 2030: evidence and solutions for achieving health, welfare and economic development shows that between 28-32% of the global burden of disease is amenable to surgical treatment, yet as many as 5 billion people worldwide lack access to surgical care, predominantly in LMICs. An additional 143 million operations are required each year to save lives and prevent disability from surgical conditions, and 33 million people face catastrophic expenditure paying out-ofpocket for surgical care. The report also identifies key opportunities for local and global collective action to address these challenges and to assure better global surgical care for all by The international community can support national governments in realising the health, welfare, and economic development gains of better surgical and anaesthesia care through the following actions: Advance health, welfare, and development by improving access to surgical and anaesthesia care Provide targeted health systems financing to the poorest countries for surgical scale-up Low-income and lower-middle income countries will require external financial support from the international community to scale-up surgical care in order to meet population needs. Provision of direct financial support for health systems strengthening, with targeted funding for surgical care, will be crucial to achieving the health, welfare and economic gains conferred by improved surgical care in the world s poorest regions. Support surgical capacity building in LMICs by fostering collaborative partnerships with local providers International global health agencies, academic institutions, charitable organisations and professional associations can support surgical capacity building in LMICs by developing collaborative partnerships with national governments and local providers. These partnerships may be especially useful for supporting surgical workforce development, education and training, as well as the design and delivery of coordinated surgical services within health systems. For partnerships to be effective they must promote codevelopment, address locally articulated needs and support local capacity building in a manner that is sustainable and ethical.

11 Embed surgical and anaesthesia care and strong health systems within key global health and development goals Support global health financing policies that promote equitable and affordable surgical and anaesthesia care in LMICs Access to safe, affordable, and timely surgical care in LMICs can be significantly accelerated through universal health coverage (UHC). UHC seeks to safeguard people from the financial uncertainty associated with using health services while promoting equity. Accessing surgical care is currently associated with high levels of catastrophic expenditure and impoverishment in LMICs, especially amongst the poorest, because payment for surgery is mainly out-of-pocket. International institutions must support health financing policies and mechanisms that allow countries to progress towards pro-poor UHC. This includes assuring financial risk protection against the costs of surgical care early in UHC expansion pathways, by providing coverage for a basic package of essential surgical care. Recognise the importance of surgical and anaesthesia care in achieving the health-related Sustainable Development Goals The international community plays a powerful role in agenda-setting and norm promotion in global health, including shaping the post-2015 Sustainable Development Goals. Surgical care is a key component in a functional and resilient health system and is needed for the management of a diverse range of common conditions in LMICs. However this has previously been poorly recognized by international global health agencies. The international community must acknowledge that surgical care is an integral tool for health and economic development in LMICs, including achieving the health-related SDGs. In particular, surgical care will have a key role in the management of non-communicable diseases (NCDs) and injuries, two rapidly growing health challenges in LMICs that are set to feature prominently in post-2015 global health goals. Advance global knowledge, knowledge translation and implementation science for surgical and anaesthesia care Support epidemiological, clinical and health systems research for better global surgical and anaesthesia care International institutions and organisations can play a key role in supporting research on the global burden of surgical disease, the value and cost-effectiveness of specific clinical interventions and platforms for managing surgical conditions in LMICs. They can also support health policy development focused on improving access to safe and affordable surgical care and delivery of surgical services at the population level. To maximise the impact of research on outcomes, the international community should focus on developing effective research collaborations with local providers and national governments and on collecting information that can directly inform country-specific improvements in surgical care.

12 Provide technical assistance and policy support for the collection and monitoring of global surgical indicators Global health and development agencies can play a central role in tracking and reporting surgical care as part of efforts to monitor broader gains in health. These agencies must include the Commission s core indicators for monitoring universal access to safe, affordable surgical care when needed within their monitoring frameworks, including the World Bank s World Development Indicators and the new Global Reference List of 100 Core Health Indicators. All agencies using comprehensive household surveys for health including The World Bank, WHO and USAID should support countries in collecting data about surgical conditions and surgical care by including uniform and validated questions for surgery within their household surveys (e.g. LSMS, DHS, MICS). Facility-based surveys (e.g. the WHO Hospital Assessment Tool) should similarly include consistent and validated questions for surgical care. Indicators and targets for the new post-2015 health and development goals, including the SDGs and those for UHC, should include the preparedness for, delivery of, and impact of surgical care. Support and finance innovations in equipment and technology built specifically for low-resource contexts The international community, in collaboration with LMIC partners, should increase efforts to research, develop, and finance low-cost, effective and durable surgical and anaesthesia equipment and technology designed specifically to meet the needs of low-resource environments. High-income countries can also benefit from this process through the collaborative development of effective, low-cost innovations for surgical care which are applicable to both low-resource and high-resource settings. Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development was written by The Lancet Commission on Global Surgery, an international multi-disciplinary group of 25 Commissioners, in consultation with collaborators in over 110 countries and all major regions of the world. The Commission is chaired by Dr. John Meara, Dr. Andy Leather, and Dr. Lars Hagander.

13 Global Surgery 2030 evidence and solutions for achieving health, welfare, and economic development Policy Brief: ACTIONS AND OPPORTUNITIES FOR LOW INCOME AND MIDDLE INCOME COUNTRIES Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development provides a compelling argument that surgery is an indispensable part of a functional health system for countries at all stages of development. In most low-income and middle-income countries (LMICs) access to safe, affordable surgical care when needed remains out of reach for over 90% of the population. In the absence of surgical services, common, treatable conditions such as appendicitis, broken bones, and obstructed labour have high death rates. In addition to the health impacts, untreated surgical conditions significantly affect economic productivity, growth, and development. The Global Surgery 2030 report shows that without urgent scale-up of surgical care, LMICs will have projected economic losses from surgical conditions estimated at $12.3 trillion dollars (2010, US$, PPP) between , reducing annual income growth by as much as 2% in some countries. However the report also outlines that scale-up of surgical care in LMICs over the next fifteen years is affordable, cost-effective, feasible, and can result in widespread health, welfare and economic returns on investment, both for individuals and their countries. Although the causes of inadequate and inequitable surgical care are a global concern and responsibility, improvements in surgical care will ultimately be realised at the national level, through the programs, services and policies implemented in LMICs by national governments and delivered by local providers. Global Surgery 2030 outlines key recommendations for countries to follow, including a template for a national surgical plan, that can accelerate surgical scale-up and facilitate substantial health, welfare, and economic gains. Improve health, welfare, and economic development through increased access to surgical and anaesthesia care Scale up surgical and anaesthesia care, focusing on attaining good population coverage with first-level surgical services To improve health, welfare, and economic development in LMICs, national governments must make a political commitment to scale-up surgical care, and mobilise the necessary human, technical and financial resources to do so. In the poorest countries, the focus should be on attaining good population coverage with first-level (district) hospital services capable of providing safe and timely surgical care. Global Surgery 2030 identifies three key indicator operations that predict the ability of a first-level hospital to provide a broad range of essential surgical services: these are caesarean delivery for obstructed labour, laparotomy for abdominal emergencies, and treatment of open fractures following trauma. In middle-income countries, where there is generally better coverage with basic surgical care, a focus on quality, safety, and equity in access to surgical care is needed. All countries should aim for a minimum operative volume of 5000 procedures per 100,000 population in order to realise associated health and development gains.

14 Increase domestic spending on health and invest in the health system, including surgical and anaesthesia care Scale-up of surgical care in LMICs will require both broad health systems investment and targeted financing of surgical services, including investments in physical infrastructure, equipment, supply chains, and human resources. The total cost of surgical scale-up represents about 1% of current total annual health expenditures for upper-middle income countries, and about 6% and 8% for lower-middle income countries and low-income countries respectively. Although the costs of achieving surgical scale-up are high, particularly in the poorest countries where surgical resources are severely lacking, the projected economic benefits of scale-up significantly exceed the costs of the initial investment. While low-income countries will require some external assistance to finance surgical scale-up, many middle-income countries will be able to meet the costs of scale-up through the mobilisation of domestic resources alone. Aggressively scale-up human resources for health, including for surgical and anaesthesia care One of the major barriers to realizing the health, welfare, and economic gains better access to surgical care can bring to populations is the severe deficit of trained providers in LMICs. This includes surgical, anaesthesia and obstetric (SAO) providers, as well as those in ancillary services such as laboratories, blood banks, radiology, pathology, nursing, and physiotherapy. Countries must be proactive in planning, funding and implementing human resource programs for surgical care, at both a training and vocational level in order to meet population needs. Ministries of Health should develop surgical workforce plans to achieve surgical workforce SAO densities of per 100,000 population with adequate rural and urban distribution. Wherever possible graduate and postgraduate training of surgical providers at accredited institutions should occur within the country, and trainees should be exposed to a variety of practice settings including rural settings. The international community can partner with countries to strengthen training and expand the surgical workforce by providing technical and financial support. Embed surgical and anaesthesia care and strong health systems within key national health and development goals Develop a national surgical plan to quantify baseline surgical capacity and track progress over time Ministries of Health should develop a national strategic health plan that specifically addresses surgical care and sits within a broader strategy for national health system improvement. A national surgical plan is essential for the proper planning and delivery of services, training and research. Global Surgery 2030 provides a template for a national surgical plan that addresses five major domains of surgical system development: infrastructure, workforce, service delivery, information management, and financing. This template also provides recommendations to national governments on areas of focus for step-wise improvement in each domain, as well as methods to monitor and evaluate progress.

15 Commit to health financing mechanisms that provide financial risk protection and promote health equity In order to improve access to surgical care and reduce poverty associated with paying for surgical treatment in LMICs, countries must commit to the introduction of health financing mechanisms that safeguard people from catastrophic health expenditure. For many LMICs this requires moving away from direct health financing mechanisms that rely on out-of-pocket payment for surgical services at the point of care, to indirect financing mechanisms such as general taxation and social insurance, which pool risk. Universal health coverage (UHC) should be the ultimate goal of national governments. Governments should adopt health policies that support progressive expansion of services towards UHC, and commit to covering the poor (who are the most likely to face impoverishment from disease) from the outset. Include surgical and anaesthesia care within the essential package of health services covered under Universal Health Coverage (UHC) policies Although surgical care can improve health and fight poverty in LMICs, use of surgical services can also be impoverishing for households in the absence of effective financial risk protection. National UHC policies should cover a minimum basic package of essential surgical care early in the coverage expansion pathway. The precise components of such a package should be determined at a country level. Several features of surgical care necessitate its inclusion within essential health coverage packages in LMICs. A substantial proportion of surgical conditions in LMICs are time-critical and life- or limb-threatening. User fees for surgical care are often high and payments made out-of-pocket by patients can result in large rates of catastrophic expenditure and impoverishment relative to other health interventions. Emergency surgical conditions (e.g. trauma) are not predictable, making it difficult for households to foresee, plan, or save for the financial outcomes. Ensure health policies and services aimed at curbing maternal and neonatal deaths, non-communicable diseases, and injuries include provision of surgical and anaesthesia care Surgical care plays an integral role in averting death and disability from maternal conditions such as obstructed labour, neonatal conditions such as cleft palate, NCDs such as breast and cervical cancer, and injuries. Governments must therefore ensure that health policies and services targeted to the prevention of maternal and child deaths, NCDs, and injuries specifically make provision for surgical services in order for these policies to be effective.

16 Advance knowledge, knowledge translation, and implementation science for surgical and anaesthesia care Develop clinical audit, impact evaluation, and health research capabilities to generate locally relevant data on surgical and anaesthesia services and outcomes. Measuring surgical volumes, baseline surgical capacity and surgical outcomes at a country level are important for identifying and addressing strengths and weaknesses in surgical care provision. Ministries of Health, academic institutions, and health service providers can all participate in monitoring and evaluation and research activities to generate locally-relevant surgical and anaesthesia data. Commit to collecting data on key surgical indicators and use this data to monitor progress and inform health policy and service provision Ministries of Health should commit to collecting data on key global surgical indicators, as outlined in the Global Surgery 2030 report. These indicators cover access to timely essential surgery, specialist surgical, anaesthesia and obstetric workforce density, surgical volume, perioperative mortality rate, and measures of financial risk protection at the country level. Collection of standardized surgical indicators allows countries to identify areas of unmet need and monitor progress over time, as well as benchmark their performance against that of other countries at similar levels of development. It is vital that collected data is used to inform rationale decision-making by countries regarding policy-setting and resource allocation. Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development was written by The Lancet Commission on Global Surgery, an international multi-disciplinary group of 25 Commissioners, in consultation with collaborators in over 110 countries and all major regions of the world. The Commission is chaired by Dr. John Meara, Dr. Andy Leather, and Dr. Lars Hagander.

17 Global Surgery 2030 evidence and solutions for achieving health, welfare, and economic development Policy Brief: MONITORING SURGERY AND ANAESTHESIA FOR IMPROVED HEALTH, WELFARE, AND DEVELOPMENT This is a year of transition for global health, welfare, and development goals. In 2015, United Nation member states will adopt a set of Sustainable Development Goals (SDGs), and numerous international agencies including the World Bank, World Health Organization (WHO) and USAID will decide upon 100 core health indicators for monitoring progress towards Universal Health Coverage (UHC). The Lancet Commission on Global Surgery s compelling new report, Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development, demonstrates that realising these new goals will not be possible without including universal access to safe, affordable surgical and anaesthesia care when needed as a fundamental aim. The pivotal role of surgery in improving health and welfare Surgical conditions account for approximately 30% of the global burden of disease, and the need for surgical intervention spans 100% of disease sub-categories. Widespread provision of surgical care can greatly decrease death and disability. For example, surgery is responsible for approximately 65% of cancer cure and control, and increased access to caesarean delivery reduces neonatal mortality by up to 70%. The magnitude and ubiquity of surgical conditions makes tracking their prevalence and treatment within local, national, and international monitoring systems essential to fully capture the health and welfare of populations % of the global burden of disease can be attributed to surgically treatable conditions The powerful role of surgery in poverty alleviation and economic development Global Surgery 2030 highlights the grave economic consequences of untreated surgical conditions. Without urgent scale-up of surgical care, the projected GDP loss from five major categories of surgical conditions between 2015 and 2030 in low- and middle-income countries (LMICs) is $12.3 trillion. This will reduce annual GDP growth as much as 2%. Using a Value of a Statistical Life method (which captures the intrinsic value people put on improved health and longer lives that cannot be captured by GDP measures alone), the report finds that illness and death from surgical conditions resulted in $4.0 trillion in total welfare losses in LMICs in Seeking surgical care can also pose significant financial risks to individuals. Global Surgery 2030 found that 33 million cases of catastrophic expenditure occur annually from the direct medical costs of seeking surgical services, and an additional 48 million cases occur each year when non-medical costs, such as food and transportation expenses, are included. One quarter of all people who have a surgical procedure will face financial catastrophe as a result of seeking care.

18 Creation of indicators to monitor access to safe, affordable surgical and anaesthesia care when needed Using new research to demonstrate their feasibility, availability and importance, The Lancet Commission on Global Surgery developed six core surgical indicators, as well as accompanying targets that will be necessary to realize emerging global health, welfare and development goals, with an emphasis on those relating to UHC. These indicators are structured around preparedness for surgical care (access to surgery and workforce density), delivery of surgical care (surgical volume and perioperative mortality rate), and impact of surgical care (protection against impoverishing expenditure and catastrophic expenditure). These indicators are intended to be used in tandem, collected at a national level and reported at a global level (Table 1). Indicator Definition Rationale Data Sources Responsible Entity Comments Target Group 1: Preparedness for surgical and anaesthesia care Access to timely essential surgery Proportion of the population that can access, within 2 hours, a facility that can do caesarean delivery, laparotomy and treatment of open fracture (the Bellwether procedures) All people should have timely access to emergency surgical services. Bellwether procedure performance predicts accomplishment of many other essential surgical procedures; 2 hours is a threshold of death from complications Facility records and population demographics Ministry of Health Informs policy and planning regarding location of services in relation to population density, transport systems and facility service delivery A minimum of 80% coverage of essential surgical and anaesthesia services per country by 2030 Specialist surgical workforce density Number of specialist surgical, anaesthetic and obstetric physicians who are working, per population The availability and accessibility of human resources for health is a crucial component of surgical and anaesthesia care delivery Facility records, data from training and licensing bodies Ministry of Health Informs workforce, training and retention strategies 100% of countries with at least 20 surgical, anaesthetic, and obstetric physicians per population by 2030 Group 2: Delivery of surgical and anaesthesia care Surgical volume Procedures done in an operating theatre, per population per year The number of surgical procedures done per year is an indicator of met need Facility records Facility, Ministry of Health Informs policy and planning regarding met and unmet need for surgical care 80% of countries by 2020 and 100% of countries by 2030 tracking surgical volume; procedures per population by 2030 Perioperative mortality rate (POMR) All-cause death rate prior to discharge among patients who have undergone a procedure in an operating theatre, divided by the total number of procedures, presented as a percentage Surgical and anaesthesia safety is an integral component of care delivery; perioperative morality encompasses deaths in the operating theatre and in the hospital after the procedure Facility records and death registries Facility, Ministry of Health Informs policy and planning regarding surgical and anaesthesia safety, as well as surgical volume when number of procedures is the denominator 80% of countries by 2020 and 100% of countries by 2030 tracking perioperative mortality; in 2020, assess global data and set national targets for 2030 Group 3: Impact of surgical and anaesthesia care Protection against impoverishing expenditure* Proportion of households protected against impoverishment from direct out-of-pocket payments for surgical and anaesthesia care Billions of people each year are at risk of financial ruin from accessing surgical services; this is a surgeryspecific version of a World Bank universal health coverage target Household surveys, facility records World Bank, WHO, USAID Informs policy about payment systems, insurance coverage, and balance of public and private services 100% protection against impoverishment from out-of-pocket payments for surgical and anaesthesia care by 2030 Protection against catastrophic expenditure Proportion of households protected against catastrophic expenditure from direct out-ofpocket payments for surgical and anaesthesia care Billions of people each year are at risk of financial ruin from accessing surgical services; this is a surgeryspecific version of a World Bank universal health coverage target Household surveys, facility records World Bank, WHO, USAID Informs policy about payment systems, insurance coverage, and balance of public and private services 100% protection against catastrophic expenditure from outof-pocket payments for surgical and anaesthesia care by 2030 Table 1. Access, workforce, volume, and perioperative mortality indicators should be reported annually. Financial protection indicators should be reported alongside the World Bank and WHO measures of financial risk protection for universal health coverage. These indicators provide the most information when used and interpreted together; no single indicator provides an adequate representation of surgical and anaesthesia care when analysed independently. USAID=US Agency for International Development. Equity stratifiers are listed in report s discussion. *Impoverishing expenditure is defined as being pushed into poverty or being pushed further into poverty by out-of-pocket payments. Catastrophic expenditure is defined as direct out-of-pocket payments of greater than 40% of household income net of subsistence needs.

19 Actions and opportunities monitoring surgery and anaesthesia for improved health, welfare, and economic development Include indicators of universal access to safe, affordable surgical and anaesthesia care when needed within national and international monitoring frameworks Timely treatment of surgical procedures can boost economic development for countries, decrease poverty for families, augment health for individuals, and help realize new global health, welfare, and development goals. Surgical care is needed to reach the proposed health-focused SDG (ensure healthy lives and promote well-being for all at all ages by 2030), and the two World Bank targets for UHC (80% essential health services coverage and 100% financial protection from out-of-pocket payments for health services by 2030). Global health and development agencies can monitor progress towards new global goals for health and economic development by including the Commission s six core indicators within their indicator monitoring frameworks, including the World Bank s World Development Indicators and the new Global Reference List of 100 Core Health Indicators. The new post-2015 health and development goals, including the SDGs and those for UHC, should include indicators and targets for surgical care. LMICs can help realize UHC by including surgery within UHC expansion pathways, using the Commission s six core indicators to monitor progress towards coverage of essential health services and financial protection from out-of-pocket payments for health care. Private providers working outside of the government to deliver surgical care (including non-governmental organisations), should also collect the six core indicators in order for countries to capture all surgical care delivery. Countries with more advanced monitoring systems can collect additional disaggregates to allow further sophistication in data analysis. Incorporate surgical conditions and surgical care within population- and facility-based data collection methods The burden of surgical conditions is large and growing, and surgical care is needed across all disease subcategories. LMIC national health systems can increase their knowledge of the health of their populations and health care services provided by including surgical conditions and surgical care within comprehensive population- and facility-based monitoring systems. All international agencies using comprehensive household surveys for health including The World Bank, USAID and UNICEF - can support countries in collecting data about surgical conditions and surgical care by including uniform and validated questions for surgery within household surveys (eg LSMS, DHS, MICS). Facility-based surveys (eg WHO Hospital Assessment Tool) should similarly include consistent and validated questions for surgical care. Expand accounting frameworks to capture funding flows to global surgery Scaling up surgical care to meet population needs, alleviate poverty and boost economic productivity will require wide scale investments, but there is currently no way to track funding flows for surgery. Capturing funding flows for surgery can increase transparency, accountability, and efficiency of financial resource use for health services. LMICs can track funding flows for surgery by following expenditure by intervention or clinical service within their national health accounts. Similarly, Global Overseas Development Assistance or Development Assistance for Health databases (eg the OECD DAC and OECD CRS databases) can expand their accounting framework to allow for monitoring expenditure by intervention or clinical service to capture funding flows to surgery. The International System of Health Accounts should include and collect surgical data to allow standardised reporting and comparisons of expenditure on surgical care and its financing. Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development was written by The Lancet Commission on Global Surgery, an international multi-disciplinary group of 25 Commissioners, in consultation with collaborators in over 110 countries and all major regions of the world. The Commission is chaired by Dr. John Meara, Dr. Andy Leather, and Dr. Lars Hagander.