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August 2018

Why are people dying following surgery in Africa?

Bruce Biccard's picture

Surgery is a core component of health. It is a cost-effective intervention1 which is important for global health.2 However, to fully realize the health benefits of surgery, it needs to be safe. In the African continent—with a population of 1.2 billion people—it is estimated that approximately 95% do not have access to safe and affordable surgery. The Lancet Commission on Global Surgery has established six indicators to indicate the success of providing access to safe and affordable surgery.3 Four of them are included in the World Bank’s World Development Indicators (WDI) database. The perioperative mortality rate (POMR)—the number of in-hospital deaths from any cause in patients who have undergone a procedure done in an operating theatre, divided by the total number of procedures—is one of the indicators the success in achieving safe surgery, yet it is not included in the WDI as the data is sparse, including the one from Africa. The recent publication of the African Surgical Outcomes Study (ASOS) has cast an important light on the POMR in Africa.4

ASOS has shown that for patients in Africa fortunate enough to access surgical care, the patient outcomes following surgery are relatively poor. ASOS demonstrated that African surgical patients were twice as likely to die following surgery when compared to the global average, despite a similar complication rate to the global average (Table 1). This is despite the fact that surgical patients in Africa are relatively healthy when compared with similar international surgical patient cohorts,5 and one would thus expect them to do well postoperatively. Therefore, if the data from ASOS had been risk-adjusted for patient comorbidities, it is likely that the mortality following surgery in Africa is more than twice the global average. The results from ASOS are compelling as they provide comprehensive data on surgical outcomes in Africa, from 25 countries, 247 hospitals, and over 11,000 patients.

Table 1. Mortality, complications and ‘failure to rescue’ following surgery

Source: ISOS International Surgical Outcomes Study ASOS African Surgical Outcomes Study4
(elective surgery)
(elective surgery)
(elective and emergency surgery)
Mortality 207/44 814 (0.5%) 48/4792 (1.0%) 239/11193 (2.1%)
Complications 7508/44814 (16.8%) 624/4658 (13.4%) 1977/10885 (18.2%)
Death following complication
(failure to rescue)
207/7508 (2.8%) 30/620 (4.8%) 188/1970 (9.5%)