Where are essential surgeries being performed and monitored? A global update on volume reporting

In 2015, the Lancet Commission on Global Surgery (LCoGS)—an expert group composed of commissioners, global collaborators, and affiliated researchers—developed six core surgical indicators to facilitate monitoring of World Health Assembly Resolution 68/15 objectives to improve access to safe and affordable essential surgical care.  Amongst these indicators is surgical volume, defined as the number of operative cases performed per 100,000 population. Surgical volume serves as an important metric to monitor progress toward addressing the nearly 143 million additional operations per year required to minimize disability and avoid preventable deaths due to surgically treatable conditions.
 

Global progress in reporting on surgical volume: Updates from 2023

There has been a notable uptick in the number of countries worldwide reporting on surgical metrics since 2015. From 2010 to 2016, a research group affiliated with the World Health Organization Collaborating Centre for Surgery and Public Health performed a sweeping review of available literature and databases and found 72 countries that reported on national surgical volume.

In order to assess temporal progress in surgical volume reporting, this review process was repeated by researchers at the University of California San Francisco’s Center for Health Equity in Surgery and Anesthesia (CHESA). The data retrieval process included a systematic review of major bibliographic databases, health ministries and national statistical databases, and internet searches of grey literature.

Of the 216 countries and economies classified by income levels by the World Bank, we found 123 countries (56.9%) that reported on surgical volume by 2023. This represents a 70.8% increase in the number of reporting countries since 2016 (Table 1). Momentum for increasing the proportion of reporting countries each year has not slowed, even after considering the effects of the COVID-19 pandemic (see Figure 1 for cumulative progress over time). Despite these gains, there remains an urgent need to increase the overall availability and consistency of surgical volume reporting worldwide. 

Where do we stand with the Lancet Commission on Global Surgery targets for 2030?

To address the global lack of safe and timely treatment of surgical conditions, the National Surgical, Obstetric, and Anesthesia Plan, developed by LCoGS, proposed target metrics to be reached by 2030, including a minimum annual surgical volume of 5,000 surgeries per 100,000 population. Approaches to achieve these target are ambiguous. This is particularly relevant for low-income countries which lack the appropriate infrastructure and support to implement new strategies for nationwide data monitoring.

As of 2023, 45 countries (36.6% of those reporting and 20.8% overall) have achieved the LCoGS target of 5,000 procedures per 100,000 population (Figure 2). However, only two lower-middle-income countries (LMICs), Ukraine and Mongolia, and none of the low-income countries (LICs) according to the World Bank classification, represent the 45 countries meeting this LCoGS target. 
 

It is apparent that low- and lower-middle-income countries are disproportionately affected by barriers to regular monitoring and reporting of surgical indicators, including lack of funding, appropriate data ecosystems or electronic data platforms in place of paper chart filing systems. These same regions receive only 6% of the global surgical volume and suffer high case-fatality rates from conditions that are easily treatable with surgery. The COVID-19 pandemic further exposed gaps in the capacity of operative care services globally, resulting in significant yet avoidable morbidity and mortality, particularly in lower-income contexts. Urgent, strategic investment in surgical care systems can strengthen routine care delivery in these contexts while also promoting resiliency in the face of future epidemics or pandemics.

 
Reviving global efforts to increase regular, reliable surgical volume reporting

Progress with global surgical indicator reporting has steadily increased since 2015, yet surgery continues to lag behind other areas of global health despite rising awareness of the role of essential surgery and the global burden of surgical disease. Access to safe and affordable surgical care is poorest in LICs and LMICs, and investment in surgical strengthening in these countries can save lives and stimulate economic growth.

Nearly a decade after the LCoGS targets for 2030 were released, fewer than one third of countries globally and one in seven LMICs report national surgical volume on an annual basis. Continued, coordinated efforts at all levels are required to achieve LCoGS target surgical volume and eradicate global burden due to treatable surgical conditions. Particular attention and resources must be directed toward LMICs, where the latest data reveals slow progress toward improving surgical systems through regular reporting of surgical indicators.